Trying Again: Getting Pregnant After Miscarriage-- Amos Grunebaum, MD-- 03/08/04
By Amos Grunebaum
WebMD Live Events Transcript
Trying to get pregnant after miscarriage can be scary and confusing. When can you try again? What are your chances of success? What are the causes of miscarriage? We addressed these questions and more when Amos Grunebaum, MD, medical director of the WebMD Fertility Center, joined us in WebMD Live.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Member question: Should I insist on tests after a first miscarriage to determine the cause?
Dr. Amos: After one miscarriage your risk of having another one is not increased. So most doctors do not suggest doing any testing after one miscarriage. Having said that, it also depends on your medical history. For example, some second trimester abortions may be associated with an incompetent cervix, but most first trimester abortions are due to chromosomal anomalies, and the next pregnancy will usually end in a healthy baby.
Member question: I've had a miscarriage before. I had FSG and day three blood testing and his semen analysis done and all results are normal. What else do I need to do to locate my problem for not being able to conceive?
Dr. Amos: If you ovulate regularly AND he has a normal sperm count then the next step is usually to check the fallopian tubes. This is usually done with a hysterosalpingogram or a laparoscopy. If all theses tests are normal and you cannot get pregnant then the diagnosis is 'unexplained infertility.' Many couples with unexplained infertility will eventually get pregnant. Many doctors, though, feel that with unexplained infertility the fastest way getting pregnant is with IVF.
Member question: Is miscarriage after seeing a healthy fetus and heart beat common?
Dr. Amos: No, that's uncommon. Once you see the fetal heart beat above 100 beats per minute your risk of having a miscarriage is well below 10%.
Member question: I had a miscarriage after seeing a healthy baby with 150 heart beats at seven weeks. Since development was apparently good but I ended up having a miscarriage four weeks later, what are some possible causes?
Dr. Amos: Most cases of early miscarriages, likely well over 60%-70%, are due to chromosomal anomalies. Doing a chromosome count on the fetus can help you better identify the cause. Unfortunately, many doctors do not do this test, so it's impossible to know exactly what happened. And if this was the only miscarriage, you chances having a healthy baby after the next pregnancy are excellent.
Member question: l had a stillborn at 27 weeks. I started contracting and after two hours went into labor with back pains. When I got to the hospital I was already dilated with the membrane bulging. The autopsy report of the placenta stated acute chorioamnioitis and accelerated maturity. We did not have the baby autopsied. How long does it take for infection to cause a stillborn and do you think there I may have an incompetent cervix, since one doctor thinks so but my own doctor said no? I am ready to try again and I am very worried.
Dr. Amos: I am so sorry to hear about your stillborn baby. Not knowing your complete history makes it difficult to assess what was going on. It could be an incompetent cervix, though babies born with incompetent cervix are usually not stillborn. It all depends on how long you were in labor and how long it took for the cervix to become fully dilated. But if that happened really quickly then an incompetent cervix is on top of the list.
An infection can happen quickly, within hours, especially if the cervix is already dilated. I hope you are seeing a high-risk obstetrician, a maternal-fetal medicine specialist who is best trained to help your next high-risk pregnancy. Good Luck!
Member question: I have a friend who had a miscarriage on Feb. 26, and about three days after her doctor put her on Wellbutrin SR to relieve her emotions, but I believe that they are just normal emotions like crying (not uncontrollably) and only put her on it for 30 days. But what I have read says it takes two weeks just for it to start working, so would that mean she will only have an effective amount for two weeks. Is this normal to be put on it after only two days after a miscarriage?
Dr. Amos: The only person to decide whether your friend needed this medication or not is her doctor. It's impossible for me to second-guess the doctor's indication. It's not unusual to provide patients with emotional issues with medications and to makes sure that they feel better.
Member question: Is it true that miscarriages that occur after a certain point are always a result of a defect in the fetus and not something that could have been prevented?
Dr. Amos: By far most if not all miscarriages are not due to something the mother did or didn't do, and the vast majority happens because there is a defect in the fetus, either chromosomal or otherwise. Early miscarriages are more often due to abnormal fetuses than late miscarriages; late miscarriages can sometimes be due to an incompetent cervix or an infection.
Member question: I got severe preeclampsia and HELLP with my first pregnancy (delivered stillborn at 23 weeks) and was later diagnosed with blood clotting disorders. What are the chances that I will have preeclampsia again if taking heparin?
Dr. Amos: Unfortunately, a history of this condition has an up to 50% risk of recurring in the next pregnancy. Seeing a high-risk obstetrician BEFORE you get pregnant may help you have a healthy pregnancy, and taking heparin may also help you decrease the risk of having early preeclampsia again. In addition, you need to be monitored very closely throughout the pregnancy.
Member question: Is it true that patients having PCOS will ovulate poor quality eggs and if the poor quality eggs get fertilized it will lead to miscarriage? Is there a treatment to improve the quality of eggs?
Dr. Amos: You are correct. Patients with PCOS have an increased risk of miscarriages. Some of them are due to the quality of the eggs and others due to abnormal implantation and uterine lining.
Unfortunately, you can't do much about the quality of the eggs, but seeing an infertility specialist, a reproductive endocrinologist, may help you find out what if anything can be done to improve your chances of having a healthy pregnancy.
Member question: I had a miscarriage in June 2003 at 8 weeks and have been TTC since. I have had blood checked and recently an HSG and everything looks good (blood results good and tubes are open). DH had a sperm analysis and that was all fine too. I am using the Clear Plan Fertility monitor to know when I ovulate so that we time intercourse at the right time. I am getting very frustrated that we are not getting pregnant. What is our next step?
Dr. Amos: You are on the right path. Having had his sperm count done was an important first step. The next step is to make sure that you are ovulating regularly; then the next step is to check the fallopian tubes.
You should know, though, that timing intercourse exclusively based on the fertility monitor has never been proven to increase your pregnancy chances. It may actually decrease your chances if you make love only when the fertility monitor says so. The best thing to do, if you know that you ovulate normally, is to make love every week 2-3 times. That ensures you are not missing your important fertile days.
Member question: I had a tubal reversal Jan. 5, 2004, became pregnant and miscarried this weekend. My hCG level is supposed to be monitored to prevent a tubal pregnancy. Is there a guideline of average hCG level per week?
Dr. Amos: I am sorry to hear about your miscarriage. There is no real absolute hCG number. But they should decrease over time and disappear within four to six weeks.
Member question: My son was stillborn due to antiphospholipid syndrome. Is it possible to have recurrent stillbirths?
Dr. Amos: With antiphospholipid syndrome there is a risk of blood clots in the placenta. These clots can lead to several complications including a stillbirth. The treatment is usually heparin in the next pregnancy. Heparin can decrease the risk of blood clots and the risk of stillbirth. However, you are an extremely high-risk pregnancy and I hope you are seeing a maternal-fetal medicine specialist. These high-risk doctors are best trained to guide you through pregnancy and help you have a healthy baby.
Member question: It seems that ob-gyns often see a pregnant patient for the first time when she is six to eight weeks. If you have had a previous loss should you be seen earlier?
Dr. Amos: I always suggest seeing your ob-gyn BEFORE you get pregnant, as soon as you start TTC. This allows you to discuss all of your issues beforehand and make sure you know what to do and what not to do. That way you can ask when your doctor wants to first see you. Many patients could benefit from seeing the doctor as soon as the pregnancy test is positive, but it's even better to see your doctor as soon as possible.
And don't forget to take daily folic acid. Folic acid needs to be started one to two months prior to conception. Taking it decreases your risks of fetal malformations and miscarriages.
Member question: I had a miscarriage at eight weeks in January, waited through one normal cycle, and just started TTC again. Is this too soon?
Dr. Amos: No, it's not too soon. Waiting for one menstrual cycle after an early miscarriage is usually sufficient. Waiting longer to get pregnant will not improve your chances of having a healthier pregnancy.
Member question: I had a miscarriage at five weeks (in July '03) and have had three chemical pregnancies since then. My RE does not seem to be concerned. Celiac sprue runs in my family; do you think this is concerning and should I be tested for celiac or other problems?
Dr. Amos: I can't decide from here whether you should get tested or not, but you are in good hands seeing an RE. Most doctors will do some additional tests after two to three miscarriages in a row and make sure there is nothing else going on that needs treatment. Celiac sprue is usually not a major contributor to miscarriage causes.
Member question: I am 39 (40 in three weeks) and miscarried at eight weeks in June. I never got AF or ovulated on my own and have taken prometrium/clomid (150 milligrams) and a hCG trigger shot for the past three cycles and am still not pregnant. My FSH level last cycle was 7, which my doctor said was excellent. Can you tell me your opinion on FSH levels? Also, I'm considering IVF and want to know what the chances are.
Dr. Amos: FSH levels can vary a lot, but most doctors likely feel an FSH level of 7 on CD 3 is normal. If you did not get pregnant after three ovulatory cycles (you didn't mention if you did ovulate or not) then most doctors feel that your chances are better with IVF.
Member question: Yes, I ovulated and the SA was normal.
Dr. Amos: So after three ovulatory cycles you should consider IVF. Good luck to you!'
Moderator: Thanks again to Amos Grunebaum, MD, for talking TTC with us.
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