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Dr. Jones: Early miscarriage is common, the most common complication in pregnancy. How do we think about our options to manage this?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: About one million American women experience early pregnancy failure each year. This is the loss of a pregnancy in the first 12 weeks. Before the common use of early pregnancy tests and ultrasounds, women often didn't even know they were pregnant for several months. Now, women know that they're pregnant if they want to within two weeks after fertilization, and an ultrasound of five to six weeks from the last menstrual period, four weeks after fertilization can show early fetal development and whether the pregnancy is developing as it should.

As many as 60% of eggs that are fertilized don't lead to live births. Most of those aren't even recognized as a pregnancy. But for women who've had a positive pregnancy test, 15% to 25% of those pregnancies will not proceed past the first trimester, the first 12 weeks. Early pregnancy loss is common, and it may be that recognized as cramping and bleeding early in pregnancy, signs of the pregnancy is probably going to end in a spontaneous abortion without any medical intervention.

All over the world women miscarry early, and most do not get or need medical intervention. However, with the use of early ultrasound at six weeks from the last menstrual period, we can see if the pregnancy is going to fail. If there's a sac without a heartbeat or a fetus, or if there's a tiny area that might have been an early fetus that doesn't have a heartbeat, that pregnancy will probably miscarry. However, it may take weeks to months for that to happen on its own.

Some women are willing to wait for nature to take its course -- have their miscarriage, pass their tissue, or may just be heavy bleeding. They won't really see a fetus because one hasn't developed. But some women want to get on with their reproductive lives, end this pregnancy so they can start again if they want to.

In the U.S. in past years, women who had access to early pregnancy care and found that they didn't have a heartbeat were recommended to have a D&C. This is a procedure in the operating room with anesthesia. The cervix is stretched open with a dilator, and a tube is passed into the uterus to aspirate the sac and the early placenta. This is expensive -- it can cost thousands of dollars -- and time consuming.

Techniques that have evolved over the last 20 years include using a syringe with a suction device and a little tube to remove the failed pregnancy, and this can be done in about five minutes in the office under local anesthesia. Many physicians are familiar and comfortable with this option, and they counsel this option for the patient. But many are not and are most likely to counsel going to the operating room.

Over the past 15 years, medications have been studied that can cause the uterus to cramp and push out the pregnancy. One of these medications, Misoprostol is widely available and has been used especially in women who've already started to cramp and bleed as they begin to miscarry early. One large study found that this oral medication is as successful in women experiencing early pregnancy failure as a surgical procedure if they've already started cramping and bleeding. The risk of heavy bleeding and infection were not any different in the surgical procedure than the medical one.

If women have an early pregnancy that isn't growing, doesn't have a heartbeat or an ultrasound, but they haven't started cramping and bleeding yet, taking this medication is less successful than if women have already started the process. A recent study published in "The New England Journal of Medicine" compared women who took the cramping medicine called a uterotonic Misoprostol with women who were given the same combination of drugs as women use when they are choosing a medical abortion. This combination has been used safely by millions of women around the world for the past 20 years, and it combines a medication called Mifepristone followed by Misoprostol.

This randomized trial showed that women who were given just the cramping medicine when they had a failed early pregnancy demonstrated by ultrasound, they were successful in completing a miscarriage at home within 4 days and about 67% of the time. Women who were given the two medications were successful in ending the failed pregnancy, but in 4 days 84% at the time. Women who hadn't completed a miscarriage in four days were offered another dose of medication. Some women who didn't complete their miscarriage had a suction procedure to finish the miscarriage.

Most women were satisfied with the process and said that they would recommend it to a friend and they would choose this way of ending an early pregnancy loss if it happened to them again. Now, not all physicians are familiar with these medications and not all pharmacies carry them. But these options can become an important choice for some women.

So how do you use this information? Early pregnancy failure can be devastating to women who've been hoping for a baby. Once the ultrasound findings that there's no growing fetus are explained, a woman may choose to wait until nature takes its course, knowing that this might take days to weeks. Some women want it all over with as soon as possible and are comfortable with the surgical procedure and are not comfortable with what can be significant cramping and bleeding that can come with a spontaneous abortion or with the medication.

Some women want the timeliness of taking the medication rather than waiting, but want the privacy of being at home, knowing that they can call their physician if they're having any difficulties. However you and your clinician come to manage this problem, it's often an emotional roller coaster, a big loss, as well as a physical loss. Make the choices that work the best for you and get the information that will help you move forward. And thanks for joining us on The Scope.

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Interviewer: You had a miscarriage and you're trying again, but for whatever reason, you can't get pregnant again. Is this normal? We'll find out next, on The Scope.

We're talking to Dr. Kirtly Parker Jones, the expert on all things woman. Dr. Jones, the scenario is, you and your partner got pregnant. For whatever reason, unfortunately got a miscarriage and you're trying again, but it's been a while and you can't get pregnant again. Is this normal?

Dr. Jones: Okay, good question, and the answer is, it depends.

Interviewer: It always depends.

Dr. Jones: It all depends. So the rate of miscarriage in healthy couples under 35 is about 15 percent. It's very common. And if people got pregnant relatively easily, it means they weren't taking years to get that pregnancy that miscarried, they got pregnant easily, then it is not normal for them not to be able to get pregnant again. And the vast majority of people get pregnant again.

Now, sometimes, the miscarriage is a sign of an underlying problem. So let's take the 40-year-old who took three years to get pregnant. She miscarried, she can't get pregnant. Now it's been a year or two. That miscarriage was probably a sign, along with that three years of trying, that she was running out of eggs. And now, she's kind of more run out of eggs.

So sometimes a miscarriage is a sign of an underlying problem that's getting worse, and in fact, it's true for sperm problems. So men with abnormal sperm can have more miscarriages, and in the process, their sperm is getting more abnormal. So it was sort of abnormal and they had a miscarriage, and now it's really abnormal, they're not getting pregnant.

Interviewer: So it can depend on both the woman and the man.

Dr. Jones: Right.

Interviewer: Okay.

Dr. Jones: And lastly, sometimes the treatment for a miscarriage. For example, let's say you miscarried, you passed some tissue you didn't pass at all, so they had to go in, you had a little infection in your uterus, so they did a D&C, and in the process of doing that D&C in a scarred, in an infected uterus, the uterus got scarred. And so that can be the cause of the secondary inability to get pregnant.

But for the majority of people who are not old, and they got pregnant easily, and they miscarried, the majority of them, 85 percent to 90 percent, will be pregnant again within a year. So not getting pregnant is not normal.

updated: May 9, 2019
originally published: June 29, 2017

Interviewer: When is it too late to have a baby from a woman's point of view? I know that there are a lot of couples that are putting that off later and later in their life until they're more comfortable. I've always heard 40 is the cutoff. Is that the cutoff or not?

Dr. Jones: Well, actually yes and no. There is a decline in fertility that begins at about age 28. Now, it isn't like 28 turns the switch off or that 40 turns the switch all the way off, and there's variability from woman to woman but the point is that there's no test. You can't drive in and plug your ovaries in and say, "Am I still fertile?" So, the biggest issue about waiting too long is not that you're going to have a baby with a birth defect or that you're going to have complications of pregnancy, is that you're not going to get pregnant at all.

Interviewer: Really? Because I always thought that after 40, the percentage of complications increased dramatically, is that not true?

Dr. Jones: It starts... so, the question is complications, what's dramatically and when does it start?

Interviewer: And what are complications?

Dr. Jones: And what are complications? It always depends, right? So, in fact, I think what people are mostly worried is that the complications of having a baby with a birth defect, that's not something that a doctor can actually fix, so we're talking about complications for the mom, complications for the baby, and complications genetically.

So, we know that the older the egg is, the more complications there are in terms of abnormal chromosomes. Trisomy 21 or Down syndrome is the one that most people know about. Well, that number actually starts going up in the 30s.

And so the chance at 35 is about 1 in 200, the chances at 40 is about 1 in maybe 100, the chances at 44 might be 1 in 20 to 30.

Interviewer: Okay, so, these chances are that there could be genetic defects in the egg, not necessarily that that's going to translate into anything bad.

Dr. Jones: Well, because most genetic defects in the egg lead to no baby at all.

Interviewer: Okay.

Dr. Jones: So, when we're talking about abnormalities in the egg, most of the eggs after women get to their late 30s are abnormal.

Interviewer: Okay.

Dr. Jones: So, if most of the eggs are abnormal, then most of those won't actually even make a baby.

Dr. Jones: So, the chances of getting pregnant and staying pregnant goes down from your early 30s on but it goes down rather dramatically after 35. So the biggest issue is getting pregnant because the chances of getting pregnant goes down and staying pregnant because of those abnormalities leading to miscarriage. So, the rate of miscarriage in women in their early 20s might be 15 percent, by their 30s it might be 20 percent, but by their 40s it might be 40 and then getting into 50 percent.

And that's miscarriage of those that are detected. A lot of pregnancies that start actually don't even get hard enough to be called a miscarriage.

Interviewer: Oh, really?

Dr. Jones: Now, we haven't talked about sperm yet but please, let me take that opportunity. We know that men as they get older have abnormal sperm too. So, aging and sperm isn't good for sperm and there are diseases that are more common as men age. So sperm quality goes down with age but usually not dramatically until men are a little bit older into their late 40s, 50s, and 60s. So, there is that issue. That's the chromosomal issue that people are worried about.

Clearly women as they get older have an older body. They have more hypertension. They may have more diabetes. They have issues that make them more likely to have complications in pregnancy. All of those go up with age but mostly those things you can get around with a good doctor and a good hospital.

Interviewer: So, not too much to worry about there generally.

Dr. Jones: Generally. Now, the good news for those people who would use the technology is that we have technology that's less invasive to pick up those genetic defects that increase with age. So, women who are older, who manage to get pregnant and manage to stay pregnant can do some early screening and make decisions about continuing a pregnancy if they find that they have a genetic defect.

Now, this is taking populations. Clearly, there are some women who start to run out of eggs earlier and so they'll be less fertile in their 30s, and there are some women blessed with a whole bunch of extra eggs. Those women who have late menopause and they have babies early and often have babies without difficulty, well into their early to mid 40s, but it's rare for any population you study that women have successful pregnancies after 45 with any kind of frequency.

Interviewer: So, for that couple that may come into your office, it sounds like it's a case by case basis, really.

Dr. Jones: It is.

Interviewer: And it sounds like getting pregnant is the hardest part. The other issues not so much.

Dr. Jones: Getting pregnant and staying pregnant.

Interviewer: Yeah, the other issue is not so much the concern.

Dr. Jones: Now, these are low-risk women so if a woman that comes in who's diabetic or one that comes in who's hypertensive, or someone who's come in who's had cancer treatment. Their are situations that are going to be much different. And of course it's not that you should run out and have babies when you're most reproductively fit, which might be your early 20s because you may not have pair-bonded, you may not be ready for the responsibility, for the rest of your life of caring for another person that way. So, that's always a trade-off.

But I think people should be aware that if postponing the pregnancy is a lifestyle issue, meaning, you've pair-bonded, you have enough time, effort, and money to be a good parent, then, putting things off does not really help you very much if you really want that kid.

Interviewer: So, what's the major takeaway that you'd have?

Dr. Jones: The major takeaway is that postponing a pregnancy can be great as a lifestyle issue but remember all these things have trade-offs. So if you're busy in your career and you're busy trying to find someone to pair-bond with, to raise children with, the later you wait, there may be some consequences. We have all kinds of technology to help people who wait too late. So we have what we could do for people who got to their 40s and can't get pregnant or stay pregnant, and we can use other people's sperm, we can use other people's eggs. There are all kinds of stuff we can do but if you wait until after your mid 30s to start a family, it may not go as easily as you hope.

Interviewer: So, the getting pregnant, staying pregnant aside, is 40 too late? Is 45 too late? Is 50 too late? Is there a cutoff line?

Dr. Jones: No, there's not a cutoff line because people... I'd love to say every pregnancy was planned. Remember half our pregnancies aren't planned and we don't say, "Oh, you're so late. You can't carry this pregnancy." No, it's not too late in the sense that I think it's just being informed, and I think most people now know that if you have a baby in your 40s, if you get pregnant in your 40s, there are going to be more things to screen for, more issues to screen for the baby in terms of chromosomal birth defects, but if you can get pregnant, stay pregnant, and have the early screening, you're probably going to be okay.

updated: May 23, 2019
originally published: August 21, 2014