The 10 most common questions about miscarriage

Written by Dr Weng Chan
14 Oct

Miscarriages are a lot more common than most people think, with one in six pregnancies ending before week 20.

For women and couples experiencing miscarriage, it’s important to remember that they are not alone. October 15 is Pregnancy Loss Remembrance Day, raising awareness in the general community about the burden of miscarriage and help to reduce the stigma associated with it.

Along with the emotional toll a miscarriage can take on couples, a major source of frustration is being left with a myriad of unanswered questions. Unfortunately even in cases of recurrent miscarriages, investigations will pinpoint a cause in fewer than 50% of cases. Whilst this adds to the frustration it can also mean you are more likely to achieve a healthy pregnancy in the future. 

Following are the most common questions people ask about miscarriage:

How do I know I’m having a miscarriage?

Miscarriages can present in many ways, with some women experiencing a period like pain and bleeding.  For others, there may be no symptoms and the miscarriage is picked up incidentally on a routine ultrasound. In some cases, an ultrasound can pick up features that the pregnancy may not be optimal and further testing or follow-up may be required by their fertility specialist. To confirm a viable pregnancy an early dating scan is recommended. If this is confirmed, then the chance of a miscarriage occurring is greatly reduced.

My mum/sister experienced recurrent miscarriage, does that mean I will too?

As miscarriages are common, it is not unexpected that other family members may have suffered one or more miscarriages.  There are numerous causes of miscarriages, depending on the individual’s and family’s medical history, the timing of conception and when the miscarriages occurred. Some of which can run in the family, sometimes it may be co-incidental.

What are the main causes of miscarriage?

The majority of miscarriages occur as a result of genetically abnormal embryos.  Conditions that are also known to lead to recurrent miscarriage are blood clotting disorders; endocrine disorders; submucosal fibroids; and other structural abnormalities in the womb; as well as hormonal issues commonly seen with polycystic ovaries. In a small percentage of people, a genetic abnormality can be passed down resulting in miscarriages.

How does the woman’s age increase the risk of miscarriage?

Because women are born with a finite amount of eggs and these eggs age as we do, women over 35 face an increased risk of miscarriage as the quality of the eggs decline.  By the time a woman has turned 43, there is a 50% chance a pregnancy will miscarry. With aging, there can be an increased amount of exposure to oxidative stresses which affects the DNA which makes up the important genetic material of a woman’s eggs. This affects the health and quality of the eggs and ultimately the quality of the embryo and its risk of miscarrying. It’s important to remember that no matter how healthy you are or how young you feel, this will not prevent the quality of your eggs declining with time and the risk of chromosomally abnormal pregnancies increase with age.

Does a man’s age increase the risk of miscarriage?

While a man’s age does not have the same impact on his fertility compared with women, the quality of sperm does decreases with age, especially after the age of 40 which may increase the risk of miscarriage and also infertility. In the same way that aging increase’s a woman’s eggs exposure to oxidative stresses, affecting the DNA of genetic material, so too does it affect a male’s sperm, and ultimately the quality of the embryo. The risk of miscarriage is twice as high for women whose male partner is aged over 45 than for those whose partners are under 25.

Does stress increase my chance of miscarriage?

The causes of pregnancy loss are complex and are usually due to chromosomal abnormality in the embryo, and not increased with personal or work stress, excessive exercise or travel.

How soon after a miscarriage can we try to conceive again?

Doctors generally advise giving your body the chance to have 1 or 2 periods before trying again to fall pregnant. This is also useful for dating the pregnancy. However, it is important you wait until both partners feel ready both physically and emotionally to try again. One should consult their treating doctor with regards to this depending of the circumstances leading to the miscarriage and the treatment.

What can we do to prevent miscarriage? 

While there is no way to prevent a miscarriage happening, there are some controllable lifestyle factors such as smoking, drug use and obesity which are known to increase the potential for miscarriage.  This also optimises one’s health from a fertility and pregnancy point of view.

There are a small percentage of people that carry a genetic abnormality, or what is known as parental chromosome abnormalities such as translocations. Embryos with unbalanced translocations usually result in a miscarriage; Pre-implantation Genetic Screening (PGS) can help improve their chances of having a healthy baby in these circumstances.

What treatments are available to avoid miscarriage occurring?

Unfortunately the management of miscarriages can be complex and the care will need to be individualised with the fertility specialist and the couple.

There are various advanced tests available to help detect the likelihood of another miscarriage and to prevent it from occurring in the future.  The most common one is Preimplantation Genetic Screening (PGS) which can be included as part of an IVF cycle. PGS allows for screening of all chromosomes in a developing embryo so only the embryo/s with normal chromosomes are selected for implantation, decreasing the risk of miscarriage from an abnormal embryo.

If a submucosal fibroid or uterine septum is diagnosed as the cause of miscarriage, the removal of these may improve the chances of implantation.

What should we do if we experience multiple miscarriages?

A small percentage of couples may experience more than one consecutive miscarriage. Three or more consecutive or ‘recurrent’ miscarriages affect around 1% of couples trying to have a baby.

Couples that have experienced recurrent miscarriages should consider seeing a fertility specialist to discuss their unique situation, undergo an assessment and have a treatment plan tailored for them.

Based on individual cases, the fertility specialist may offer testing as well as early monitoring of a pregnancy with blood tests and ultrasounds. If the need arises, then early diagnosis and treatment of any issues can be expedited.

Fertility specialists with their links to specialised fertility clinics can also offer additional support for patients from experienced nurses to counsellors, whom are experienced in the care of women in the early stages of their pregnancy.

Learn more: Miscarriage Treatments in VIC, Miscarriage Treatments in NSW, Fertility Specialists in TAS, Miscarriage Treatments in Singapore

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Thankfully for the vast majority of people, post mortem sperm retrieval will never become a reality.

It is an extremely complex and challenging area of reproductive medicine, involving retrieval of sperm after a man’s death so that it can be used by his surviving partner.

While new assisted reproductive technologies are allowing more people than ever to fall pregnant and start the family they desire, the law, at times, does not keep pace with these developments.

In Australia, the law does not specifically address the issue of retrieval and use of sperm after a man’s death. So, while a partner may be sure she knows what her partner ‘would have wanted’, without supporting legal documents explicitly stating those wishes, the question of retrieval and use of sperm is not clear.

In most cases, an urgent court order is needed to retrieve sperm. This is a problem because while the judge is coming to a decision, every hour that the sperm lies in the body after death decreases the chance of finding live sperm.

While 24 hours is the accepted time period for successful retrieval, there may still be a small chance up to 36 hours after death.  However, while retrieval might be medically successful, the court may never permit a woman to use the sperm.

I co-authored a paper, published in the Australian and New Zealand Journal of Obstetrics and Gynaecology, in which we surveyed 28 IVF clinics across Australasia to test attitudes towards posthumous sperm retrieval and use.

It appears that directors of IVF units are generally supportive of the practice, given the right circumstances, but that the lack of clear laws makes the response to requests for sperm retrieval very difficult.

Myself, and the papers co-authors, believe that ‘clear, accessible and consistent law in this area would benefit everyone involved, including the medical, legal and societal stakeholders’.

It is not only the law that needs to catch up. In the same way that people discuss organ donation, I believe that couples should discuss post mortem sperm use.

Men should consider and discuss with their partners whether they would want to father a child after their death, bearing in mind that they could not raise the child, and that the child could conceivably be raised by another man.

I need to be clear that I am not suggesting that more people should have their sperm collected and used after their death.

Personally, I wouldn’t want my sperm to be retrieved and used if I died suddenly, and my wife knows this. But, if couples don’t have the discussion and document their wishes, it is seldom clear what one would have wanted if one dies.

Have you considered discussing post mortem sperm retrieval with your partner?

Dr Weng Chan
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How healthy are IVF children?

This project was the largest of its kind ever attempted, worldwide.

We found that children conceived by IVF grew into healthy, normal adults when compared to children conceived spontaneously.

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Self-report of their health and wellbeing for the first 18 years of life found the ART children had a normal body mass index and similar history of pubertal development to those spontaneously conceived. Educational outcomes, including tertiary admission ranked scores and completion of tertiary education, were also similar.

Were there differences in the health of IVF-conceived children?

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These problems are more common in premature babies and we know a higher proportion of ART babies are born prematurely for reasons still largely unknown. Premature births may be because of the age of IVF mothers, as having a baby in your early 40s is generally harder than having a baby in your late 20s or early 30s.

ART parents might take their children to the GP more often and consequently they are diagnosed at a higher rate. We found ourselves speculating if parents of IVF-conceived children are more protective reducing their baby’s exposure to dust and dirt in turn increasing their risk factor for later allergies.

The finding of increased hospitalisations, including in the secondary school years, has not been examined in other studies to date and the reasons for hospitalisation varied, with no consistent set of conditions. Again, we wonder if this is due to parental vigilance.

What will be done to investigate further?

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We have a responsibility to continue this research and gather further clinical review in long term follow up of those conceived through IVF and other ART. Further research will evaluate their health status and follow up to determine if there are any important lifelong medical or other legacies of IVF.

What does this mean for those considering IVF?

This study provides reassurance to those requiring IVF that there are no apparent substantial negative long term health and wellbeing effects on young adults compared to those spontaneously conceived.

This study is published in Fertility and Sterility. 

Learn more about IVF in Queensland, Victoria and New South Wales.



 

Dr Weng Chan
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15 years of IVF patients – how have women changed?

The media is increasingly full of stories showcasing the latest 50 year old mum, or the celebrity who has undergone IVF. Even women who have used donor eggs are increasingly more comfortable discussing their medical history.

But, do these sensationalised stories really reflect the changing face of the IVF patient we see every day at our fertility clinic?

At Queensland Fertility Group Toowoomba we decided to assess the reality of these changes. In order to do this we conducted a retrospective study of 1587 women who had undergone IVF between 1998 and 2013 at our clinic in Toowoomba (based in the Darling Downs, west of Brisbane). We know that during this time there has been considerable social change, and we were interested to see how our patients may correspondingly have changed during this 15 year period.

Older women

Studies carried out by the Australian Institute of Health and Welfare informs us that the average age of women receiving treatment using their own eggs or embryos, is 36 years. We know too that over the last 20 years the average age of women giving birth has increased by 7.5%.

What did our study of 1,587 women show? The average age of women undergoing IVF treatment in Toowoomba has significantly increased by 6% - from 33 years in 1998 to 35 years in 2013.  Interestingly, the major shift has been the marked increase in the number of women aged over 39 completing treatment - which 15 years ago was just 3% and by 2013 had grown to 18%.

Rising obesity

The number of overweight and obese Australians has been gradually increasing for the past 30 years across all demographics – from wealthy, metropolitan suburbs to rural and disadvantaged communities.

An Australian Bureau of Statistics Australian Health Survey identified that between 1995 and 2011/12 the average adult woman’s weight had increased by 4kgs. The report likewise stated that in 2011/12 27% of all females aged 18 and over were overweight with a Body Mass Index (BMI) of 25 to 30.

Toowoomba is no exception to this trend. It’s therefore not surprising that the average IVF patient has become heavier. Women undergoing IVF treatment in 1998 at QFG Toowoomba had an average weight of 66kgs, and this had increased up to 77kgs by 2013. More significantly, their BMI (which also takes into account their height) moved from normal at 24 to overweight at 28 in 2013.

Single Women and Same-sex Couples

Shifts have occurred in the structure of families and as a result, we have seen a considerable increase over the past five years in single and same-sex couples accessing donor sperm to start their families.

Looking at the subset of patients where female cause was the sole reason for them having treatment, the proportion of single women and same-sex couples undergoing IVF increased from 2% in 2008 to 22% in 2013.

15 years later

Women attending our fertility clinic in 2013 are significantly older, heavier and have an increased BMI than they did in 1998. However, as women delay child bearing, by choice or circumstance, we need to ensure that there isn’t an unrealistic expectation that medical science can undo the effects of age.

What would you advise?

Unfortunately, we still cannot reverse the aging process, but we can ensure women are given the correct information to help them make informed decisions earlier. For example, the increasing use of the Anti-Mullerian Hormone (AMH) test or as it's more widely known, the egg timer test, can help a Fertility Specialist better assess a woman’s fertility and guide the direction of her fertility treatment.

Many women still remain unaware of the effect of weight on their fertility. We advise weight loss with simple lifestyle changes and, if necessary, dietician support. In addition to boosting a woman’s natural fertility, this can also have a beneficial impact on pregnancy and the health of the child.

This data was presented by Leita Fien, Fertility Nurse, Toowoomba at the 5th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2014) in conjunction with the Fertility Society of Australia Annual Conference held in Brisbane April 4-6, 2014.  Leita would like to acknowledge and thank her co-authors and colleagues Susan Lax, Julie Logan, Jeremy Osborn, and Dr John Esler, Clinical Director QFG Toowoomba.

Dr Weng Chan
14 Oct

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