61. Recurrent Miscarriages: Finding Solutions

In this episode of Cycle Wisdom, Dr. Monica Minjeur discusses proactive approaches to reduce miscarriage risk, especially for women who have experienced recurrent pregnancy loss. As October marks National Pregnancy and Infant Loss Month, Dr. Minjeur offers support, evaluation techniques, and treatments that help improve fertility outcomes. Learn about hormone imbalances, genetic factors, and lesser-known causes of miscarriage—and how charting cycles and targeted interventions can make a difference for women hoping to achieve and maintain a healthy pregnancy. 

Transcript

Monica: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. October marks the start of National Pregnancy and Infant Loss Month, which encompasses miscarriage, stillbirth, SIDS or sudden infant death syndrome, preterm birth, and other congenital health conditions leading to the loss of a young life. I would like to start out by sending out lots of love to all families who have experienced the unexpected loss of a pregnancy or an infant after birth. If you are not already connected to an organization to help you through this, there are lots of groups nationwide that specialize in walking with families throughout the many milestones after a loss. Although every path is different, for many people this becomes a lifelong journey, but there is support and hope available. One of my favorite organizations here in the Midwest is called No Foot Too Small. You can find them online. There are also lots of different local counseling groups in your area, as well as church organizations, hospital groups, and community resources that are available if you're looking for professionals to help guide you in the right direction and connect with other families who have gone through a similar loss. On today's podcast episode, I'm going to be talking about evaluation that can be done even prior to achieving a pregnancy to help decrease your chances of miscarriage, especially if you have already had more than one early pregnancy loss. I will discuss some things to consider when evaluating for any underlying reasons you may have had a miscarriage, as well as how to be proactive about correcting those issues. Now, the topics I discuss today may not apply to every single pregnancy or loss situation, but if we can address any causes that have modifiable factors, we can improve the chances of a successful pregnancy, And also correct underlying health conditions in the meantime. Now some people get upset when they first hear about these types of evaluations because they weren't offered to them in the past, or other doctors have told them that hormone evaluation during pregnancy isn't a thing. Now, I want to give just a short disclaimer here that if you're not yet ready to hear this information because the loss of a pregnancy is too new for you, feel free to skip this episode. You can always come back to it when you're ready for the next steps on your journey. However, if you're ready to learn more, let's start off as always with a patient story. So today we're going to talk about Tiffany. Now she came to see me when she was 34 years old and at this point in time she had had three pregnancies and unfortunately all three of those pregnancies ended in a miscarriage before 12 weeks. She was still wanting to achieve pregnancy but was obviously very concerned about her past miscarriage history. Now, after her third miscarriage, her OB doctor did some blood tests and told her everything was normal. Unfortunately, Tiffany didn't know exactly what had been checked, and she didn't think anything was checked with her hormone levels, and she definitely didn't have any observations of her charting at that time. So the first step is that we got Tiffany started working with one of our charting instructors to start tracking her cycles, not only when she was having her periods, but also when she was ovulating, how long her fertile window was, as well as monitoring her luteal phase from the time that she ovulated until her period happened. And what we found was that She had a quite shortened luteal phase, and when we reviewed all of her other symptoms, she did also have some significant PMS symptoms. When I ordered her targeted labs, it confirmed my suspicion that Tiffany had both low progesterone and estrogen levels. Now what we did next was we worked on targeting the treatment to improve and optimize her levels Prior to achieving a next pregnancy and we waited until her progesterone and estrogen levels were better ranges Before we gave her the green light to try and achieve another pregnancy Now she did achieve another pregnancy fairly quickly and we checked her labs early, so as soon as she knew she had that positive home pregnancy test, we had her in for a lab draw the next day. Based on those lab levels, we were able to continue her on some bioidentical progesterone, as well as supplements to help support her estrogen and other hormone levels over time. throughout her pregnancy. I monitored her levels, been anywhere between one to four weeks depending upon how things were going, and we also checked an early ultrasound around seven weeks. Now, with all of this intervention, Tiffany went on to deliver a healthy full term baby at 39 weeks. Now, it's not always this straightforward, and sometimes we do end up finding that we have another miscarriage before we get all the pieces figured out. However, in Tiffany's case, we were able to find answers. We were able to treat ahead of time and we had a clear plan in place for when she did achieve pregnancy again, how we were going to be able to monitor those hormone levels throughout her cycle. So how common is miscarriage? Statistics are a little bit cloudy on this and we find that roughly 10 to 20 percent of pregnancies end in miscarriage. Now this may be underestimated because many people don't even realize that they are pregnant For people that check a pregnancy test at home early and then still end up miscarrying, this is oftentimes called a chemical pregnancy. Now, the difference with this is that with a chemical pregnancy, fertilization does occur, and this was the start of a life, but implantation does not occur. So again, you're generally going to get that positive home pregnancy test, but But you start another cycle, you bleed and you miscarry, generally within 7 10 days of your missed period or shorter. So if you're not tracking your cycles real clearly, sometimes people don't even know that this is what happened. Now 80 percent of miscarriages will occur in the first trimester, which is any time before 12 weeks. If you have two or more miscarriages in a row, we call that a recurrent miscarriage. And if you have three or more miscarriages, that's typically when most conventional doctors will finally start to pay attention. They may order some blood work checking for different coagulopathies or clotting or bleeding disorders. And they may recommend genetic testing. The tough thing is that if you have three consecutive miscarriages, you have a significant increase in the chance of another loss. So if you normally would only have a miscarriage in approximately 10 20 percent of pregnancies, if you have those 3 recurrent miscarriages, the chances of your having another miscarriage beyond that actually goes up to 40 50%. Now the one clarification I do want to make here is that Stillbirth is a little bit different situation and the technical clarification for stillbirth is infant death, which is at or beyond 20 weeks gestation. Now this can happen either before delivery or during delivery and generally has different causes and most of the time it's unknown. Estimates are that 50 percent of the time, whether it's a miscarriage or stillbirth, that there may be hormonal causes or or related to poor ovulation function that occurred even prior to that pregnancy beginning. And it's really difficult to know sometimes exactly what caused it, and so that's part of what we want to look at today, is figure out are there common causes, are there things that we can look at So, some of the most common things that I evaluate in my practice are going to be hormone levels and again, ideally we're checking these before you even get pregnant. Now if you have Never been pregnant, if you have never had a miscarriage, this doesn't mean that you have to get your hormone levels checked ahead of a pregnancy. But certainly if you've had even one miscarriage or if you're having a hard time getting pregnant, it's really important to make sure that not only are we tracking and charting your cycle so that we can time your lab draws appropriately, but also that we're identifying any hormone imbalances that happen before you have a pregnancy. So one of the most common things we see in our practice is a progesterone deficiency. And generally what we're going to see on your charting is a shortened luteal phase, so again the time between when you ovulate and when you have your period that that timing gets shorter. And in general what we say is anything that is going to be less than 10 days starts to get really concerning. We check your progesterone levels during that luteal phase to make sure that they reach an optimal height. Something else that we can sometimes see in low progesterone cases is if you have any brown bleeding or spotting that happens before your actual menstrual flow begins. This oftentimes is related to a progesterone deficiency and it is a sign that we can see if you're charting your cycles that can clue us into the right direction as far as what labs we need to check. Other signs or symptoms that we see with progesterone deficiency can include PMS or premenstrual syndrome, or recurrent miscarriage. Now, how we find out if it's a problem is we check your lab levels, ideally ahead of time, around 7 days after ovulation, to make sure that your progesterone levels are high enough. The other time that we're going to check your lab levels is testing them at the time that you have that positive home pregnancy test. So I always lovingly joke with my patients, when you get that positive home pregnancy test, You can tell your partner first, but I need to be the second phone call because we want to be checking those lab levels right away and starting you on treatment if needed. Now, there's a wonderful nomogram that we follow and it was created by Dr. Tom Hilgers, the founder of Napro Technology. And what this nomogram does is it follows throughout an gestational age and tells me what would the average progesterone levels be in a normal healthy pregnancy. The way that we treat them is that we utilize bioidentical progesterone and we give it to you in different formulations in order to help increase those progesterone levels. Because progesterone is incredibly important to make sure that you have a good healthy placenta, which obviously is important not only for baby's optimal functioning, health, but also for growth and making sure that nutrients are getting to the baby. So progesterone is really important. Another common thing that we look for is going to be estrogen deficiency, and this is going to show up as Estradiol is the primary source that we look for prior to pregnancy. Now things that can show up ahead of time with your cycles is that we can see decreased mucus or consistently very light menstrual bleeding. That can clue us in that there might be an estrogen deficiency. Again, if you have had low energy or recurrent miscarriage, low blood pressure, Those can be other symptoms that we notice. And again, the only way to really confirm that this is the case is to check your levels. So again, we're ideally checking levels about seven days after you've ovulated to make sure that they are optimized prior to pregnancy. And again, we're going to check the lab levels at the time of that home pregnancy test. We also follow a different nomogram, and this was created by Dr. Phil Boyle, who is the founder of Neofertility, and he has actually published some papers talking about the evaluation, monitoring, and treatment of estradiol in order to prevent recurrent miscarriage in women. Typically, for treatment with this, we are utilizing DHEA, which is a precursor to estradiol, and it encourages the body to produce more of the estrogen that is needed in order to help support that pregnancy, keep the uterine lining thick enough to help support the pregnancy, and help placental implantation to occur. Now, there are certainly lots of other causes that are a little more challenging to diagnose and I just want to talk briefly about some of these today. So, genetic causes are another thing that are oftentimes brought up by an OB, again, not typically unless you've had three or more miscarriages. And there's a couple different ways that you can have genetic testing done. One is that you can have genetic testing done of the actual fetus or embryo, so the products of conception. or an actual lab sample from the infant if they were big enough to be able to get an actual blood test from. The other type of genetic testing that sometimes is discussed is parental genetic testing. Now this is less commonly the cause and typically doesn't tell us as much as if we're looking at what happens when the two parents genetics come together, but there are certain conditions that can lead to this. Overall, we estimate that genetic reasons alone typically account for less than three to four percent of all miscarriages. Other reasons that you can have a miscarriage would be anatomic reasons. So endometriosis, which we've talked a lot about on this podcast in the past, as well as scarring or adhesions if you've had past surgeries or especially if you've had any type of pelvic surgery, c section, as well as the shape of your uterus. So again, if you have more of an arcuate shaped uterus, which is kind of a heart shaped uterus, or if you have a uterus that has two distinct separate horns rather than just a nice open area, that can also be a cause for miscarriage. And then the final section I want to talk today about is some other things that are a bit newer that are out there that we do evaluate. And generally what we're looking at is that we consider these tests and evaluation if you have had any recurrent miscarriages or prolonged issues with fertility. So, one of those things is called a DNA fragmentation index testing. And what this is, is it's actually an additional type of sperm test. And you want to check this after you've checked an initial semen analysis to ensure that that is normal. With that being said, a normal semen analysis is a good way to start. does not necessarily mean that you have normal DNA and it's obviously really important to make sure that the DNA, the genetic material that is fertilizing this egg is going to be good quality as well. So generally this test we do if you've had no pregnancy after six months of balanced cycles or if there are recurrent miscarriages. Now, this test specifically checks for DNA damage in the sperm. It is not evaluated with routine testing and it's really impossible to know or predict from history or even the routine semen analysis if the DNA fragmentation is going to be normal. So the only way we know if there's a problem is to look for it. So when DNA fragments or breaks apart, this occurs due to oxidative stress. which makes free radicals that damage the sperm cells. And now oftentimes we'll see that this is more of a problem if you are older, if you're a smoker, if you have chronic infection, stress, varicoceles, or other health conditions. And if If this testing is abnormal, we generally are going to be ordering additional lab tests for further evaluation, as well as making additional recommendations for your male partner regarding supplements, medications, and sometimes referrals if needed to help improve the quality of the DNA. Another test that we have started to do more recently is looking for what's called natural killer cells. Now this can play a role in recurrent miscarriage up to 15 percent of the time and it is a blood test, but we do have to send it to an outside specialized lab because it can't be run at most regular labs. If this test is positive, we treat with a steroid medication, typically like prednisone, from the first day that you have a positive pregnancy test until 12 weeks of pregnancy to help prevent a miscarriage. The idea is that these natural killer cells are present in your bloodstream and can actually attack any foreign being, which can include trying to attack the human body. that embryo as it's trying to implant. And so if we treat it with the prednisone, it helps calm down that inflammatory response and helps to maintain that pregnancy. Again, the only way we know if this is an issue is to do the blood test. There's nothing else that shows up on your charting or on other hormone testing that leads us in this direction. And then the final thing that's a bit newer for us is that we are starting to evaluate for what's called leukocyte adhesion defects or LAD testing. Now this is an interesting blood test that we do, and it actually needs to be blood drawn from both the female as well as the male partner. And what they do is that in the lab, they then mix together that blood to evaluate what happens with the white blood cells. And we want to make sure that there's an appropriate immune spark to ensure that implantation can occur. If there's a mismatch or if there's a problem, then there are different options which are available for treatment. Now we oftentimes will think about this LAD testing if you have an implantation failure or an early pregnancy loss. So especially for miscarriages that are happening prior to implantation occurring, so certainly prior to that 8 to 10 weeks mark, that's oftentimes something that we're going to think about. There are certainly other things that can cause a miscarriage. This is not intended to be an all inclusive list. But this is a huge way to be able to move forward and say, what else can we do? Can we evaluate in order to try and help minimize your chance for a recurrent miscarriage? Imagine if you had a systematic way to evaluate your miscarriage risk and take proactive steps to improve your health and promote fertility. This way forward is possible, and I would be honored to work with you on your unique plan going forward. If you're ready to work with our elite team of health care professionals, go to our website, RadiantClinic. com, to schedule a free discovery call with me and learn more about our package based pricing for comprehensive care. We are currently able to see people for in person appointments in our Cedar Rapids, Iowa clinic, or can arrange for a telehealth visit if you live in the states of Iowa, Illinois, or Minnesota. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.