Finding the right doctor for evaluation and care for miscarriage or recurrent pregnancy loss (RPL) can be quite the process. I am often not the first doctor patients have seen for a consult about miscarriages, and they tell me stories of filled with feelings of frustration, feeling ignored, and leaving visits with providers with more questions than answers. Providers go into medicine to care for people, and they want the best for their patients, but the fact remains that miscarriages and RPL make many providers uncomfortable.
RPL is not common. Even though 1 in 4 people will have one miscarriage, recurrent pregnancy loss affects very few. Many providers do not have a lot of experience caring for these patients and this lack of experience can make providers uncomfortable. Unfortunately, medical training for RPL is limited. Reproduction and miscarriage or pregnancy loss have not been a focus of medical school training and research in these fields is limited. Unless it is a focus of a provider’s practice, many doctors will not be up to date with current recommendations for the evaluation and treatment of RPL patients.
There are few answers for couples with RPL. Despite a thorough evaluation with the most up to date testing, up to 50% of patients with RPL will not find a reason why they are miscarrying. This is because most miscarriages are due to chromosomal issues in the embryos, but current testing focuses on issues with the people conceiving. Doctors train for years to cure illness and ‘fix’ people. The thought of doing testing and then having to tell the patients that they have no idea why they are losing pregnancies can be uncomfortable for them. Doctors want to have answers for patients just as much as patients want to have the answer to the question, "Why does this keep happening?" We are learning more and more every day about RPL, but there is still a lot we don't understand. However, providers can still give excellent care without all the answers.
Some general practitioners and obstetricians have experience with RPL, but many do not. Ask your provider about their experience and what they are willing to do, and ask at what point they will consider referring you to a specialist.
Reproductive endocrinologists (REI) and maternal-fetal medicine (MFM) specialists are the specialists for recurrent first-trimester miscarriages and pregnancy loss. These medical doctors do a four-year residency in obstetrics and gynecology and then go on to complete a three-year fellowship, with specialty training in reproductive endocrinology and infertility or maternal-fetal medicine. Not all REI or MFM specialists routinely care for patients with RPL, but many have had the training during their fellowship. If you are seeing a specialist, ask about their experience with RPL, comfort level in managing patients with RPL, plans for your evaluation and work-up, and the potential treatment recommendations.
Find someone who will listen to you and answer your questions. A provider with a background in women’s health may not have a lot of experience with RPL, but if they are compassionate and willing to learn and help, they still might be a good fit for you.
“Miscarriage is common—just try again.”
“At least you conceived. That’s the first step. It will be fine next time.”
“One or two miscarriages can happen, but we do not start testing until you have three losses.”
“Just keep trying, there is nothing else we can do.”
Some of these statements are based on good science, but they could be said in a different way and with more empathy. Most people with multiple miscarriages do go on to have healthy babies if they keep trying. Your doctor should be able to walk you through evaluation and treatment options and help you decide if any intervention is needed or whether trying again with support is right for you.
“Miscarriage is common, but that doesn’t mean it’s okay or that you’re not allowed to ask questions, get an evaluation, and grieve. Most the time the cause has something to do with the embryo – not stress, not that glass of wine you had before you knew you were pregnant, and not that cup of coffee. We should do testing to see if we can find a cause, but even without any testing or intervention, the very next time you conceive, it might be successful. Do not lose hope. When you are ready to try again, I know a positive pregnancy test is just the beginning, and I’ll be with you each step of the way.”
Dr. Shahine is a board certified reproductive endocrinologist currently practicing at Pacific NW Fertility and IVF Specialists in Seattle, WA. As a clinical instructor in the department of obstetrics and gynecology at the University of Washington and the Director of the Center for Recurrent Pregnancy Loss at PNWF, she is committed to providing excellence in patient care, teaching the next generation of women's health providers and continuing research in fields of fertility and recurrent miscarriage. She serves on the board of Babyquest, a non-profit organization which donates grants to fertility patients who need help with treatment costs.Dr. Shahine is passionate about writing. She is a regular contributor to the Huffington Post and other blogs and has authored two books. In 2015, she co-authored Planting the Seeds of Pregnancy: An Integrative Approach to Fertility Care with Stephanie Gianarelli, Lac. Planting the Seeds is a step-by-step guide to fertility evaluation and treatment from both Western and Eastern medicine approaches. In 2017, Dr. Shahine published Not Broken: An Approachable Guide to Miscarriage and Recurrent Pregnancy loss. Not Broken is an evidence based but easy to read guide for anyone who wants to learn more about the evaluation, treatment, emotional impact, and concrete steps to decrease risk of miscarriage.
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