There were two questions that I grappled with after the miscarriage. Could adenomyosis have caused what looks to be a blighted ovum or a missed abortion? Also, when could we start trying again?
These questions would not be easy to answer. There was no analysis done at the hospital to determine the cause of the miscarriage. All that I had to go on was the ultrasound scan and the description of a blighted ovum, which is when an egg and a sperm join together but with some sort of chromosomal abnormality. Your body, knowing that this embryo will not develop into a healthy baby does not develop the embryo. Many women don’t realize something is wrong until they go for an ultrasound and find there’s no embryo.
There were two possible scenarios as I saw them. I had adenomyosis. Women with adenomyosis miscarry at a significantly higher rate than women who do not have adenomyosis. So, it’s possible that this miscarriage was related to the adenomyosis. The other scenario was that I was simply unlucky. “Miscarriages are common and occur in one out of four women” (Shahine, 2017). Also, a missed abortion is believed to be the cause of 50% of clinical miscarriages (americanpregnancy.org).
What is a clinical miscarriage? A clinical miscarriage is a pregnancy loss that occurred before twenty weeks, but the pregnancy was confirmed via ultrasound before the loss. This is contrasted with a biochemical miscarriage. Thanks to home pregnancy tests, women are learning much earlier that they are pregnant. What might once have been mistaken for a late period is now sometimes discovered to be biochemical miscarriage, a miscarriage that happens too early for the pregnancy to be verified on an ultrasound (Shahine, 2017). The statistic that miscarriages occur in about 1 in 4 women does not include biochemical miscarriages. If they were included, one would find the occurrence of miscarriage to be significantlyhigher. It is believed that biochemical miscarriages are the cause of 50 – 75% of all miscarriages including clinical miscarriages (americanpregnancy.org).
This seemed right to me. It seemed true to the nature of our world that in reality when a woman gets a positive pregnancy test, there is actually only about a 50/50 percent chance that she will have a baby in her hands nine months later. In fact, the chances may be even slimmer. Shelley (2010)notes that “About half of women will miscarry at least once during their lives.”
However, we as a society rarely talk about miscarriage.
I recently read Michelle Obama’s Becomingwith my book club. Michelle talks about her own miscarriage in the book. She mentions how we don’t talk enough about miscarriage in our society, leaving women to suffer silently with feelings of shame and guilt. She, like I, would only come to learn that many of the women around her had also experienced a miscarriage after she shared her own experience. I was surprised by the number of women who after reading my blog said something along the lines of, “Maxi, I’m so sorry for what you’re going through. I also had a miscarriage, and I want you to know that I’m here to support you in any way I can.” Even the men I knew talked to me about their sisters’ miscarriages or their wives’.
When I asked my book club for other issues in society we don’t talk about enough, one woman responded with “menopause.” I found this response ironic. In 2018, I had been through menopause and miscarriage, two topics we don’t discuss enough as a society. We leave women entirely unprepared for events that can devastate them and make them question their very identity.
Who am I? How do I move on from here? Will I ever be able to have children of my own? Who am I now that my children are grown and out of the house? Where am I needed? What gives my life meaning? What do I want?
Women are too often left to face these questions alone in moments of grief and transition.
…
But back to my question, was it bad luck? Or as Shahine (2017) writes, “Although it doesn’t feel like it, women’s bodies are often working correctly when they miscarry.” Was it simply what my body was supposed to do this time?
Ben was the optimistic one. He didn’t see this miscarriage as bad luck, even. It was just the way of life. I, on the other hand, had a harder time believing that view. Or, more accurately, in order to answer my second question about when we should start trying again, I needed to know what the chances were that I would miscarry a second time.
As such, I utilized my college education to read and re-read as much of the literature I could find on adenomyosis and its effect on infertility and pregnancy. The results were inconclusive. Essentially, the reproductive process can get messed up in many ways. For instance, it could be the expression of progesterone and estrogen creating an unfavorable environment for the embryo to develop. It could be about the amount of oxygen in my uterus poisoning the embryo (Harada et al. 2016). In other words, it would be hard to identify which one or more parts of my particular system were broken if any.
With no clear answers from my own research, Ben and I decided to contact the doctor who had identified the adenomyosis, Dr. Jane. We tried to schedule an appointment with her, but she was booked solid for the next month. When we were able to get in contact with her directly, she said to wait until three months after the miscarriage before going back to see her. She did not explain why she wanted us to wait three months, and I didn’t feel like I could argue for an earlier appointment, so I moved on to the next question.
When should we start trying again?
The doctors at the hospital where I had my miscarriage suggested I wait three normal cycles after the miscarriage before we started trying again. My own research found lead me to this study result:
Couples with a 0–3-month interval (n=765 [76.7%]) compared with a greater than 3-month (n=233 [23.4%]) interval were more likely to achieve live birth (53.2% compared with 36.1%) with a significantly shorter time to pregnancy leading to live birth (median [interquartile range] five cycles [three, eight], adjusted fecundability OR 1.71 [95% confidence interval 1.30–2.25]). (Schliep et al., 2016)
Okay, so that might be a lot to process. Essentially, these researchers asked 1, 083 women between the ages of 18 and 40 how long after their miscarriage they started trying to get pregnant again. They then asked how that pregnancy ended. The vast majority (approx. 77%) of the women started trying again within 3 menstrual cycles. Of those women, 53% of their pregnancies lead to live births (a.k.a. babies!). The women who waited more than 3 cycles to start trying had 36% of their pregnancies lead to live births. So, if you try getting pregnant within three cycles, you have little over a 1 in 2 chance of that pregnancy ending in a live birth. However, if you wait more than three cycles, as many doctors are still recommending today, the chances drop to a little over 1 in 3 chances. Also, the women who started within three months had a “significantly shorter time to pregnancy leading to live birth.”
Put simply, if you try within three cycles, you can get pregnant faster and you have a 17% higher chance of that pregnancy ending in a live birth. In addition to this study, Shelley (2010) found that “women who conceived again within six months were significantly less likely to have another miscarriage.” Note that she didn’t say started trying within six cycles, she said those who had actually managed to conceive within six months. So, if I could manage to get myself pregnant again within that time frame, my chances of a miscarriage decreased significantly.
For me, these findings were important. With adenomyosis, my chances of getting pregnant again were slim to begin with. My chances of staying pregnant weren’t great either even if I could get pregnant. Also, the benefit of GnRH-a drugs like Zoladex, the medicine I received for three months to treat adenomyosis is very short. Case studies (Harada et al., 2016; Isaacson, 2016) showed that women who had been given Zoladex and similar drugs for up to 12 months saw improvements in their adenomyosis for 6-12 months after they stopped treatment. So, you could take this drug for a year, and it will benefit you for at most another year beyond that.
That did not sound good for someone who had been on the drug for only 3 months. Would I even be able to get pregnant again? I had been off the drug for three months already by the time of the miscarriage. Also, while the drug had inhibited my estrogen production, my pregnancy increased my estrogen. Furthermore, in order to medically induce the miscarriage, they gave me estrogen supplements. So, I was on 3 months of estrogen inhibition, which allowed me to spontaneously become pregnant. Then the last 2 months of pregnancy and miscarriage was a process of increasing my estrogen, so much so that my breasts increased a cup-size.
I wasn’t optimistic, but ultimately felt that all of this research suggested that we should try again soon. Waiting seemed to mean my chances of becoming pregnant again would decrease, my chances of that pregnancy ending in live birth would also decrease, but my chances of having another miscarriage would increase. So, why wait three cycles?
Well, Schliep et al. (2016) also wrote, “Although our study supports the hypothesis that there is no physiologic reason for delaying pregnancy attempt after a loss, whether a couple needs time to heal emotionally after a loss may be dependent on many factors.” This was a good point that left me with many more questions:
Was I emotionally ready for the process of trying to conceive again? It had taken a year to get pregnant the last time. This included surgery and 4 months of menopause. What if we didn’t get pregnant again right away? Was I really ready to handle that? Could I handle the possibility of never being able to experience pregnancy again?
What if we got pregnant again on my first cycle? There would be at most only two months, maybe just 6 weeks, between the miscarriage and the new pregnancy. Could my body handle that? Four months of menopause, two months of pregnancy, and now miscarriage… back to pregnancy?
What about work? The menopause, pregnancy, and miscarriage had already burdened my colleagues a great deal. I have had more classes covered for me in 2018 than in the previous three or more years. And what about my research projects? My health had significantly impacted how much I could contribute and focus on our goals. Could I really now go back to being pregnant?
If I became pregnant again, what hospital would I go to? Wouldn’t all the doctors say that they had told me to wait three cycles? Would I have allies in the medical care system here, or would I be that “know-it-all” patient in their eyes who decided to try getting pregnant right away based on Google searches? Would I be perceived as a Google MD?
What if I became pregnant and miscarried again? Could I handle two miscarriages emotionally in such a short time frame?
These were just some of the questions I faced as I dealt with all the emotion and grief of the miscarriage. There was fear; there was uncertainty; there was loneliness. I just felt like no one could really understand where I was, what I needed, and I didn’t know much more than they did.
**The featured image is of me engaging in puppy therapy with my colleague’s dog.
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