15 to 20 % of pregnancies which are recognised via a urine test or blood test or ultrasound are lost even before they reach the end of the 1st trimester. This is called a miscarriage. When this happens 2 or more times, we call it recurrent miscarriage. The reasons for miscarriage and recurrent miscarriages are similar in some ways and very different in other ways.
It is estimated that about 5% of women will experience 2 consecutive miscarriages and only about 1% experience 3 or more.
Let’s try and understand why recurrent miscarriages happen. For a successful pregnancy 3 things are required. A pregnancy or embryo that is genetically normal, a womb or uterus that is healthy and that various processes that support pregnancy in a woman’s body must be functioning well and in tandem.
Let’s address them one by one:
Embryo; this is formed by the union of the egg and the sperm. Almost 50% of recurrent miscarriages happen because of genetic problems in the embryo. There are 5 reasons for this
- God’s work: god or nature, whoever is the driving force did not want us to procreate like lower animals. Thus, certain checks were created in our fertility. Despite both parents being perfectly normal, 40% of embryos may have genetic defects and these defects can lead to miscarriages in the first 3 months. Even though we cannot see these minute imperfections, the body has very sensitive internal mechanisms and picks these up and stops these pregnancies from growing in order to prevent abnormal babies from being born. The good part about these types of miscarriages is that no treatment is usually necessary except lifestyle changes and antioxidant therapy and the next time, most likely, the pregnancy turns out just fine.
- These genetic defects can increase beyond 40% with increasing age, more for the mother than of the father. This is not surprising since with age imperfections increase in all aspects of our lives and thus there is a possibility of having even more genetic defects in the embryo. This age-related chance of miscarriages increases with each subsequent pregnancy loss and becomes almost 40% after 3 losses.
- Smoking and heavy alcohol consumption also increases the toxicity to the embryos.
- Sometimes the embryo is not at fault. In about 2 to 5 % cases, one of the parents has a genetic problem which we call as balanced or Robertsonian translocation. Basically, some mix up happens between 2 chromosomes. The father or the mother who has the problem will be normal, but this defect will cause miscarriage in their pregnancy.
- Last but not the least, sometimes the damage lies in the DNA of the sperm and can be easily identified by performing a simple DNA fragmentation test on the sperms in an IVF centre.
Let’s move on to discussing womb or the uterus now. The organ that makes a woman a mother…. the often-repeated famous Bollywood dialogue of “maine tumhari kokh se janam liya hai” This organ is vital since it must keep the baby safe inside for 9 months. 2 problems can arise in the uterus during the first 3 months that can cause recurrent pregnancy losses:
- If there is any sort of infection inside the uterus. Usually, this does not happen as again the body’s defence mechanisms are built very well. In our country however Tuberculosis is very common and this infection, if present, can probably lead to problems.
- Sometimes the uterus may contain a dividing wall inside of it, what we refer to as septum or septate uterus. This wall contains less blood supply and when the embryo implants on this dividing wall, it fails to get enough nourishment and thus may miscarry. Research papers are a little ambiguous when it comes to reporting what % of women have a septum in their uterus and of these how many women will surely have a miscarriage. Hysteroscopy or the act of putting a telescope inside the womb is the best way to diagnose and treat such problems. Because this modality of investigation has only been around a few decades now, this could be a reason why the information is sketchy. I have had innumerable patients who came with more than 4 or 5 miscarriages and when I corrected their uterine septum problem, the pregnancy miraculously settled down. Do look up my YouTube channel for videos which shows what a septum looks like or how it can be completely corrected.
It is not enough to have a plant with good roots or to plant it in the right soil, it also needs to be nurtured to enable it to grow. What are those nurturing factors in a woman’s body which if deficient or abnormal can lead to miscarriages
- Uncontrolled thyroid disease, very high prolactin levels, uncontrolled diabetes or sever polycystic ovarian syndrome can sometimes lead to recurrent pregnancy loss. Once these factors are controlled, future pregnancy becomes easy and smooth.
- Sometimes as simple as folic acid or vit B12 deficiency in the body can lead to excess of a chemical called homocysteine and this creates an unhealthy environment for the pregnancy to survive. Some women have a genetic change called MTHFR gene mutation which can increases homocysteine levels. These women need a special folic acid.
- There are some factors in the body which if present can cause increased blood clots and these can in turn cause miscarriages.
- There are some good helper cells and some bad helper cells and the balance of the two helps maintain pregnancy. Sometimes this fine balance is lost, and the bad helper cells take over thus leading to pregnancy losses.
- Natural killer cells are cells that kill foreign cells and keep the body safe. If however, these cells are in abnormal numbers inside the womb, they prevent a pregnancy from growing.
- Lastly we all know that a one cant simply accept a kidney or part of a liver from just…… anybody.. Yet…..a woman’s body readily accepts the foreign protein from a man’s sperm to make a baby. How does this miracle happen ? This is an example of the mysterious yet beautiful ways of nature wherein the maternal rejection of that foreign protein goes down in pregnancy. However sometimes by mistake this rejection increases and thus the embryo is considered foreign and rejected.
Despite all the information that I have given over the last few minutes, a cause may not be identified in up to 50% of cases. I have read about it and I have experienced it too so trust me when I say this. We doctors don’t necessarily know everything but nature is a tool far more powerful that we can ever imagine. Am sure my fellow doctors will agree with me that so many a times when all treatment and logic has failed, the problem suddenly corrects itself and all becomes well.
From the point of a couple walking into clinic with recurrent pregnancy losses, how do we doctors go about helping them. I always feel, the work of a doctor is like a detective. You must keep your mind open, ask all the right questions, pick up all the relevant cues and work in a step wise methodical manner and one day you will have the solution staring at you in the face. We follow a certain algorithm so that each fault that I have mentioned in this podcast gets evaluated and then gets treated. Yes sometimes, investigating is tougher than treatment and we do throw some stones in the dark but those are calculated guesses and do work most often. But along with this keeping a healthy mind and body is also very important. Excess body weight is also a reason for miscarriage. Exercise and diet not only help with the weight but also by healing the body from within, a more holistic approach to the treatment. But nothing works more than faith and a positive attitude so keep your chin up and tell yourself each morning that we shall get over this and get over this soon. I know that when you are going through the struggle, it just seems like a long dark tunnel and you don’t know if there is light at the end. Trust me, there is. You are not alone in this journey, there are others like you on this same dark road. With a little baby in your arms, I am sure one day you will look back with amazement at your journey. A friend of mine introduced me to these lines and I often recite them to patients…..rakh hausla ke
This brings me to the end of yet another discussion. This discussion is also available as a podcast – check out here.
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