After a Miscarriage: The Testing

Experiencing a miscarriage, or finding out your fetus has stopped growing and you will soon experience a miscarriage is devastating. When you are a fertility treatment patient, this news packs an even more heartbreaking punch. However, in the world of infertility diagnosis and fertility treatment, we believe that the more information and evidence we have, the more successful future fertility treatments will be. This belief is the foundation from which you can view your miscarriage, because we now have the medical technology to test the tissue that is shed during the event. That tissue contains pieces of placenta as well as the fetus – and we can test it to learn more about why the miscarriage happened in the first place.

Testing the Tissue from a Miscarriage Provides Crucial Information

The more we know about why it happened, the more information we have to begin planning the next step. For example, a chromosomal abnormality alerts us that it’s worth it to use Preimplantation Genetic Testing (PGT) the next time around. If the fetus seemed to have the correct number of chromosomes, we’ll take a closer look at the uterus and your immune system or we may recommend pairing IVF with PGT so we can more carefully select the next embryo(s) we transplant. Just a quick note here: In the medical/clinical world, a miscarriage may be referred to as several different things, including “abortion,” “therapeutic abortion,” “spontaneous abortion,” or “spontaneous miscarriage”. Obviously, the word abortion can be alarming for a fertility patient who is desperate to keep her baby. From a clinical perspective, the word abortion refers to, “the premature exit of the products of conception (the fetus, fetal membranes, and placenta) from the uterus… and does not refer to why that pregnancy was lost.” We want to point this out because if you have to visit an ER or go to the hospital as the result of a miscarriage, we don’t want you to be alarmed if you hear the word abortion swirling around as doctors and nurses communicate with one another. Now, back to failed pregnancies and what you can do about them.

Multiple Types or Stages of Miscarriage

There are several different types or stages of miscarriage:

Missed miscarriage

The missed miscarriage, also called a silent miscarriage or missed abortion, occurs when the embryo or fetus stops growing for whatever reason – but the body doesn’t recognize it (yet). In this type of miscarriage, especially during the earlier stages of pregnancy when you can’t feel a fetus move or kick, you may not even know anything is amiss until your next prenatal or ultrasound appointment. At that point, the doctor will express concern if your uterus has stopped growing, there is no heartbeat and/or the ultrasound confirms there is no further evidence of a heartbeat or fetal development. A missed miscarriage is the most common miscarriage scenario for women participating in fertility treatments because most treatments include the use of progesterone. Progesterone helps to keep the embryo more secure in the womb since it prevents the womb from cramping. However, this can also prevent the womb from shedding the fetus and placenta when an abnormality occurs.

Incomplete Miscarriage

This is where some of the placenta and/or fetus have passed, but some of the fetus and/or placenta is left behind in the uterus and is visible to the physician on an ultrasound. At this point, you are at risk for hemorrhaging and/or infection so you will be offered medicine to cause cramping to push the retained products of conception out or you will be scheduled in the OR for a dilation and curettage (D&C). We’ll talk more about that below.

Complete Miscarriage

While definitely devastating, this is probably the best of a worst-case scenario because your body expels all of the pregnancy tissue – placenta and fetus. In most cases, you have no control over when this occurs, which can be difficult – especially if it happens when you’re at work or out in public. The downfall for women who have a history of recurrent miscarriages, or who are using fertility treatments, is that you may not have the ability to save any part of the placenta or fetus, or you may only capture incomplete portions, which makes it more difficult to get accurate test results. On the plus side, while you will still experience shock and grief, you will not have to schedule an emergency D&C, nor will you have to schedule an appointment to speed the miscarriage along.

Blighted Ovum

Every once in a while, a pregnancy test comes back positive – and the woman experiences all of the normal signs of pregnancy – tender breasts, perhaps some morning sickness, serious fatigue, etc. Then, she goes in for her first ultrasound and what we see is an empty sac implanted in the endometrium, when we should see sac carrying and embryo with a heartbeat. This empty sac is called a blighted ovum, which is a special kind of missed miscarriage. It means that the egg was fertilized and it implanted – but development of the fetus stopped right there or very soon after. In some cases, the placenta will continue to grow – producing hormones (hCG)that tell your body (and our urine and blood tests) that you are pregnant. This can last for a week or upwards of a couple of months – telling the ovary to continue making progesterone to keep the uterus from cramping. Again, you can either wait for the placenta to eventually die off, which causes hcG and progesterone levels to drop, inducing cramping, and leading to a miscarriage. You also have the option of scheduling a D&C or a medically induced miscarriage.

Why Does a Miscarriage Happen?

Any way you look at it, having a miscarriage is a terrible experience. In the common parlance of our times – it really sucks. All you can do to take the focus off the disappointment and grief is to meet with your fertility specialist to discuss what should happen next. When our patients experience a miscarriage, they are in shock and can feel completely numb. Or, they may be completely overwhelmed by their emotions. In either case, they have a difficult time understanding or absorbing anything we have to say to them about how to proceed. Of course, their first question is always “Why?” Ultimately, 99% of miscarriages occur because there was something abnormal with the baby and/or its development. The minute the body becomes aware of this abnormality, it rejects the baby. While devastating, this is actually a very smart design. It is the reason why birth defect rates continue to remain less than 5% here in the United States. For more detailed information, we recommend reading about  , where we’ve provided additional information about the most common reasons a mother’s body induces a miscarriage.

What to Do If You Experience a Silent Miscarriage

As mentioned above, silent or missed miscarriages are the most likely scenario for women using fertility treatments because the progesterone they are taking can prevent the miscarriage from commencing on its own. If you attend an ultrasound appointment and find out the baby has stopped growing, and there is no more heartbeat, you have three options. All of them have at least a partial risk, but some are harder on your body and/or emotional well-being than others.

First Option: Schedule a Dilation & Curattage (D&C)

This is difficult, to be sure. The direct opposite of what your fertility treatment was trying to achieve, a D&C involves clearing all of the pregnancy tissues from the uterus. Patients are sedated for the procedure and their cervix is dilated. We insert a plastic tube to remove the pregnancy tissue inside the uterus. There are several advantages to scheduling a D&C as opposed to other options.

1. You are moving forward in the fertility journey, taking care of what’s happening in the moment – as opposed to having to sit and wait- like waiting for a ticking time bomb to detonate – the spontaneous miscarriage.
2. We can ensure that the proper amount of tissue is sent to a special lab for chromosomal analysis. This tissue is referred to as the “products of conception” (POC) because it contains both the placenta and the fetus.
3. You have the benefit of IV sedation, eliminating the uncomfortable to downright painful cramping that can occur during a miscarriage, and which can last for two or three days – or even longer – if the miscarriage is left to its own devices or if you choose to use medication to induce it.
4. The D&C is performed by a doctor who knows you, and whom you trust. When one of our patients miscarries, we often perform the D&C here in our office. And, of course, the D&C is performed by a doctor who is working hard to preserve your fertility, so we take extra special care throughout the entire procedure. That is a much different experience than having to be rushed into an ER operating room, and having the procedure done in unfamiliar surroundings by whomever happens to be on call at the time.

One of the rare risks of a D&C is uterine scarring. This is very rare with a suction D&C with the plastic tube but it can happen. Scarring can prevent future pregnancy and/or cause future miscarriages. That being said, it’s important to put things into perspective. The bigger picture is that an infection from a partial miscarriage has a higher risk of causing scarring, as does a D&C after an infection. In the rare case that you scar after a D&C, you may experience more milder periods than you did before because there is less endometrial tissue being shed. The good news is that most uterine scarring can be removed via surgery. Other risks include tearing of the cervix, or excessive bleeding that requires blood transfusion. Again, these are incredibly rare side effects, occurring less than 1% of the time.

Second Option: Wait it Out

The second option is to simply wait it out. If you are on progesterone supplements, you stop taking them. The hope is that your body will experience a complete miscarriage within a matter of days. Unfortunately, it can take two weeks or more – sometimes as long as two months-, which is a long time to wait. This is especially true given that the research shows fertility rates are highest for couples who start trying to conceive within three months after a miscarriage, as opposed to waiting longer. The advantages of waiting it out is that the miscarriage occurs more naturally and you have time to mentally and emotionally process what has happened before it takes place. The disadvantages are multiple. First, you risk the chance of having an incomplete miscarriage, which means you may wind up in an emergency room, being scheduled for a D&C anyway. Second, the reality is that the placenta and fetus are no longer alive, and the longer they remain in your body, the more susceptible you are to infection. While infections from this scenario are relatively rare, they can result in excess scar tissue or sepsis – the first of which compromises future fertility chances, the second of which can be fatal. Scar tissue in the uterus can result in a condition called Asherman’s Syndrome, which can be difficult to correct with surgery. Also, you have no control over when or where the miscarriage will happen. Two of our patients experienced worst-case scenarios. One was a trial lawyer who started miscarrying in the middle of courtroom proceedings and another was a teacher who started miscarrying in front of her classroom. This made an already tragic situation that much more traumatic. And that brings us to the third disadvantage of the wait it out approach; by not having control of when and where, you risk being able to collect a sufficient amount of the POC for testing, in which case helpful chromosomal analysis may not be possible, or may be inaccurate. Also, collection of the POC during a spontaneous abortion is difficult and quite messy. It entire scenario can be very traumatizing for the patient and her partner.

The Third Option. Stimulate Spontaneous Miscarriage via Medication

In addition to stopping your progesterone supplements, we can administer medications that trigger the miscarriage to start. This method is referred to as a medical abortion. There are two different medications used for this option:

1. Misoprostol. This medication is the exact opposite of Ibuprofen. It causes severe uterine cramping. Misoprostol is typically used to induce labor for women who are well beyond their due dates. In the case of a medical abortion, it is used in much higher doses to jump-start a spontaneous miscarriage.
2. Mifepristone. This medication is a progesterone blocker, and is very actively studied. Mifepristone will probably become the norm for spontaneous abortions. It is given in conjunction with misoprostol and because it blocks progesterone, it triggers uterine cramping more efficiently.

The advantage of choosing a medical abortion is that you don’t have to schedule a D&C (assuming you have a complete miscarriage). However, it’s still not a perfect solution because you have to return home and wait. In most cases, the miscarriage will occur within 12-hours. If not, you will have to come back in for a second round of medication. The disadvantage is that you still have to wait. Also, there are some bodies that simply don’t respond to the meds, even after the second dose, which requires waiting even longer or scheduling a D&C. Another disadvantage is that medical abortions can cause severe and painful cramping – yet they can still result in an incomplete miscarriage – and that leads you back to the D&C route.

Testing Miscarriage Tissue to Learn More

Whether you experience a spontaneous or silent miscarriage, saving as much as you can of the products of conception will allow us to test the tissue to learn more about what may have caused it. As we mentioned, this information provides valuable clues. When the tissue is sent for chromosomal analysis, we learn whether or not the fetus was normal or abnormal. If the chromosomes are normal, we then focus on the woman’s body – and we can continue to deepen our examination of the uterus. Or, if the uterus seems to be completely healthy, we may recommend PGT for the next round of IVF in case a detectable genetic defect was the cause. If the POC tissues test positive for abnormalities, then we know that the miscarriage was meant to happen and your body was preventing you from having a child with a birth defect. Also, can then consider IVF (if the patient used fertility meds or IUI) and/or to add PGT to the IVF mix.

Chromosomal Analysis: Karyotype Versus DNA & Computer Chip Technology

Once we send the POC to the lab, there are two different types of chromosomal analysis that can take place. The old-fashioned analysis is called “karyotyping.” This method grows the cells from the POC, after which they are viewed under a microscope to check for chromosomal anomalies. However, it’s possible that the cell sample will contain “maternal cell contamination.” This means the lab grew some of the cells from the mother’s endometrium, rather than fetal cells. If the results come back “46XX” (normal female) we don’t know for sure whether the cells were the mom’s or baby’s. There is about a 35% chance that the cells belonged to the mother rather than the fetus. Obviously, this information is not useful for creating a new fertility plan. If the results come back “46XY” (normal male), that is useful. Similarly, if the results come back “abnormal” we know there was a defect in the works and we can plan from there. We prefer using DNA and computer chip technology to text for fetal abnormalities. This is the newest technology available. It allows us to differentiate between maternal and fetal materials, providing more accurate results. With this method, we can be sure it was the baby’s cells that were tested so we can confidently proceed to the next step. If you are reading this before your first fertility treatment, good for you! This is excellent information to have on hand so you and your partner can have a thorough discussion about how you want to proceed if you experience a miscarriage. If you have learned you are experiencing a miscarriage, we hope this information will help you determine which steps make the most sense for you. While miscarrying a much-desired baby is anything but easy, even this awful step in the fertility treatment journey will take you one step closer to becoming parents. We wish you the best of luck. As always, give us a call with any questions or concerns. We’re here to help you have the family you’ve always dreamed of.