Category: pregnancy loss

I lost a part of myself that day…

I lost a part of myself that day…

I thought it was going to be easy until it was not. I thought (as a good medical student) it was just a standard medical procedure but then it was more than that. I thought the second time around would be just as the first. I wanted answers, and I wanted them fast. I wanted to know what went wrong, I wanted to fix it. I wanted to understand from a scientific point of view what caused my two precious peanut boys to stop developing. And then, after the D&C was done, and I returned home, I felt an emptiness like I never had before. I lost a part of myself that day and the days that followed.

On the surgical room, the surgeon not only removed a physical part of me but she also took the emotional and spiritual parts of me that could never be replaced.
I vaguely remember going back to school like a zombie, not feeling anything but pain and sorrow. I had to be strong enough to study, take exams, go to medical school interviews, and be a balabusta. No matter what I did, that feeling of emptiness was not going away. Every time I read or saw a video with content related to pregnancy loss, I broke into tears. During those three months of non-stop bleeding (and non-stop niddah), all I wanted was a hug and a kiss from my husband. I was furious, confused, and miserable because of that never ending niddah status. More often than not I blame myself or my overactive immune system or the medications I was on. Then I followed to blame my husband and his nonchalant attitude. Finally, it became my obsession, to the point that my hubby said it was the only thing I talked about.

But how not to be obsessed with the fact that…

I will never kiss my babies.

I will never hear them cry.

I will never change their diapers.

I will never see them crawl.

They will never have a bris, bar mitzvah, or a chasuna.

It does not matter how much time passes, I will always love them and be obsessed because I lost an essential part of who I am. But I will never forget them nor will I ever stop being thankful for allowing me to be a mother for a short couple of months.

I am now able to talk (and write) about my loss without a meltdown, without tears in my eyes. And I have started to research and read scientific journals about the causes and treatments of pregnancy loss, which has helped me find some closure and has convinced me that it was not my fault. I have finally achieved the acceptance status, no more anger, no more resentment. I feel ready to try and love again.

 

RPL: The effects of Age and Aneuploidy

RPL: The effects of Age and Aneuploidy

Just as the external physical body shows signs of aging, such as wrinkles and gray hair, the internal organs and cells also age. Thus, maternal age is one of the most determinant factors in regards to pregnancy success rates and live births. At the age of 40, it is estimated that as much as 30% of embryos are aneuploidy (a cell with an abnormal number of chromosomes), while at the age of 45, this increases to almost 100%. Thus the incidence of embryos with chromosomal abnormalities increase as maternal age increases. Most aneuploidies arise from errors in meiosis, typically due to nondisjunction (inability of a chromosome to properly separate) and account for approximately 50% of first trimester losses, 30% of second-trimester losses, and 3 % of stillborn births. Aneuploidy also accounts for unsuccessful IVF cycles when embryos are not screened.
Amongst the lethal aneuploidy category, 35% cause spontaneous abortions (such as 45X and trisomy 16, 21 and 22); while about 4% cause stillborn births (such as trisomy 13, 18 and 21). Of those aneuploidies that are somewhat compatible with life, trisomy 21, also known as Down syndrome, is the most common autosomal trisomy. Individuals with Down’s syndrome typically show signs of cognitive impairment, heart defects, and muscle weakness. The only other two autosomal trisomies that are detected in appreciable numbers are 13 and 18, however, affected individuals rarely survive the first few months of life.

trisomy21
Trisomy 21/Down’s Syndrome

On the other hand, Klinefelter’s syndrome (male 47, XXY) is an example of a sex chromosome trisomy. Affected individuals commonly show reduced sexual development and fertility, but they often have somewhat normal life spans. Monosomies are the opposite of trisomy, in that individuals affected have one chromosome less, 45 instead of 46. One uncommon monosomy is Turner syndrome (female 45, X0). Affected females have an array of symptoms, as there are a few variations of Turner’s syndrome (fully affected vs mosaicism), but typically include infertility, impaired sexual development, short stature, and heart defects.

Current Available Intervention

Couples who have conceived an embryo with an abnormal karyotype in the past, regardless of the pregnancy outcome, may be offered IVF with preimplantation genetic diagnosis (PGD) or comprehensive chromosomal screening (CCS). PGD encompasses both screening and diagnostic measures, which aims to analyze, select and transfer only embryos that have the appropriate number of chromosomes. PGD has been found to reduce the rate of miscarriage once pregnancy is achieved, but its ability to provide a better outcome for live birth compared to natural conception over time is controversial.

References:

Chromosomal Abnormalities: Aneuploidies | Learn Science at Scitable. (2017). Nature.com. Retrieved 11 August 2017, from https://www.nature.com/scitable/topicpage/chromosomal-abnormalities-aneuploidies-290

Bashiri, A., Harlev, A., & Agarwal, A. (2016). Recurrent Pregnancy Loss. Cham: Springer International Publishing.

The What, How, and Why of Recurrent Pregnancy Loss (RPL)

The What, How, and Why of Recurrent Pregnancy Loss (RPL)

Many of us, who have been in the journey of TTC for a while, might have unfortunately experienced one or several pregnancy losses. From biochemical pregnancy, early 1st trimester miscarriages, to a stillborn, each loss is emotionally tolling and frustrating. Many doctors would tell you that one loss is just an unfortunate fluke, very unlikely to happen again. But did you know that as many as 15% of all women under 35 years of age will experience an early loss (Bashiri, Harlev & Agarwal, 2016)? No woman likes hearing these statements or being a data entry in these statistics. So, like a good medical detective and curious “yenta” that I am, (and once my mourning and healing process allowed me to do so), I decided to investigate more about pregnancy loss. I hope that this information might help someone out there achieve closure, accept that you did nothing wrong to cause this, and believe that it is not your fault this happened.

But did you know that as many as 15% of all women under 35 years of age will experience an early loss (Bashiri, Harlev & Agarwal, 2016)? No woman likes hearing these statements or being a data entry in these statistics. So, like a good medical detective and curious “yenta” that I am, (and once my mourning and healing process allowed me to do so), I decided to investigate more about pregnancy loss. I hope that this information might help someone out there achieve closure, accept that you did nothing wrong to cause this and understand more about some of the causes and treatments.

What is RPL?

Recurrent pregnancy loss (RPL) is defined by ASRM as “two or more clinical pregnancies losses documented by either ultrasonography or proved in a histopathologic examination” before 20 weeks gestation. However, the “Royal College of Obstetricians and Gynaecologists (RCOG) and the European Society of Human Reproduction and Embryology (ESHRE) [defines it] as three or more consecutive losses before 24 weeks gestation”. This is a significant discrepancy, which might cause certain physicians to delay diagnosis and treatment in women with only two losses. (This is why is extremely important to understand and accept that you are your best advocate and to seek advice/treatment from an RE who is open minded and would proactively look for the patients’ input). As well, many physicians and medical societies do not count chemical pregnancies as part of the diagnosis of RPL, but after much controversy, it has been included in many studies as part of the RPL diagnosis (as implantation rate could be diminished due to poor uterine lining receptivity, uterine anomalies or blood clots).

Common causes of RPL:

RPL_Causes

  • Autoimmune disorders and other immunological anomalies
  • Parental chromosomal aberrations (genetic problems
  • Uterine anomalies
  • Endocrine/hormonal abnormalities
  • Thrombophilias/Blood clotting disorders.
  • Infections
  • Obesity/Undernutrition
  • RPL: The effects of Age and Aneuploidy

Over the next few articles, I will attempt to further examine each one of these causes and discuss potential treatments (if available).

References:

  • Bashiri, A., Harlev, A., & Agarwal, A. (2016). Recurrent Pregnancy Loss. Cham: Springer International Publishing.
  • Chromosomal Abnormalities: Aneuploidies | Learn Science at Scitable. (2017). Nature.com. Retrieved 11 August 2017, from https://www.nature.com/scitable/topicpage/chromosomal-abnormalities-aneuploidies-290
  • Schattman, G., Esteves, S., & Agarwal, A. (2015). Unexplained infertility. Pathophysiology, Evaluation and Treatment.. New York, NY: Springer.
Our infertility story and choosing a medical school

Our infertility story and choosing a medical school

The most amazing thing about applying to medical school is knowing that you gave your best in each of the 100’s of essays you wrote and the interviews you attended. Of course, it was an exhausting and money draining journey, so when I heard of my first acceptance, I was on top of the world. However, when I tell people that I was going to a DO school and not an MD school, I could see the confusion and disappointment on their faces. I don’t get me wrong; I do get that many people out there are not familiar with DO’s. Thus I take that into consideration as part of their “facial gesture assessment.”

When DH and I embarked on the journey of applying to medical school, we simultaneously started navigating the infertility road. At the time, however, we had no idea of the toll of IF treatments. A year and four months later, I was rejected from more than a dozen medical schools, put on a couple of waitlists (or what I called “death lists”) and got a couple of acceptances. On top of that, we underwent four cycles of fertility treatments, had one very early pregnancy loss (about a month or so) and an 8-week loss of our twin peanut boys, which included a D&C and three months of non-stop bleeding. The roller-coaster of hormones made me gain an awful 25 lbs, gave me mood swings, hot flashes, headaches, and what not. I went through good, bad and really tough days, plus all of the stages of grieving, while still finishing my last two semesters of school and interviewing at med schools in three different states.
After my hCG finally went down to zero, I decided that I needed a break from the fertility clinic, and doctors in general. I think at that point I was still in denial and too much pain, but it was one of the best decision I’ve ever taken. During the next six months, I took control of my health, went from a morbidly obese BMI of 32 to a healthy BMI of 25 (lost 40 lbs and still counting), graduated, and chose a great DO school instead of a great MD school.
It was not an easy decision. We weighted the cons and pros of everything, from moving to another state, the holistic vs. the conventional approach to medicines, Step 1 scores, job security for DH, and most importantly health insurance coverage.

Why was health insurance so important? Well, that’s a given, in an era where Obamacare, the insurance Marketplace, and the Trump administration are constantly scaring everyone in America about the future of healthcare coverage. However, more than that, going to the MD school meant losing our current super fantastic PPO health insurance policy ($100 deductible, 90% coverage in network and no referrals needed at all). Furthermore, the state where the MD school is located doesn’t have a state fertility mandate, which basically means that state laws specifically exclude coverage for fertility diagnosis and treatment.
This wasn’t fair! (But who said life was fair?). Once again, a curve ball is coming my way, and I have no idea how to spin it off to a home run. I certainly loved both schools and could have been happy at either, from an educational standpoint. But, what about having babies? Should we postpone having them for another four years because of lack of fertility insurance coverage? We definitely could not afford to pay for it out of pocket. So, in the end, it all came down to the possibility of having children ASAP (with the help of G-d and science). I am glad about our choice. I am a happy camper at DO medical school so far, and we are embarking in Season #2 of IF treatments, hoping for a baby (or babies) to stick with us next time around.