Deborah Howell (Host): You know, pregnancy loss is a deeply personal and heartbreaking experience that occurs more often than many realize. Today, Dr. Megan Sax, a reproductive endocrinologist and infertility specialist at Fertility Centers of Illinois, shares her insights and support on the Time to Talk Fertility podcast, providing guidance to those facing this difficult journey.

Dr. Sax, it's so nice to have you with us today.

Dr. Meg Sax: Hi there, Deborah. Thank you for having me. Pregnancy loss is unfortunately so common. Nonetheless, a lot of stigma and uncertainty remains on the topic. So, I hope our discussion today can provide patients who have experienced a loss some comfort and understanding.

Host: That's my hope as well. So, let's dive in. Can you briefly explain what pregnancy loss is and are there different categorizations for pregnancy loss?

Dr. Meg Sax: Pregnancy loss is a non-viable pregnancy or pregnancy that will not develop into a baby that's inside the uterus. In the first trimester, or less than 13 weeks' gestation, the terms early pregnancy loss, spontaneous abortion, and miscarriage can all be used interchangeably. After 20 weeks, we refer to a loss as an intrauterine fetal demise or IUFD. There are many ways you can categorize pregnancy loss, usually referring to the point in pregnancy development or even clinical presentation when the loss has occurred. For example, we may say someone has a biochemical pregnancy, if they've had a pregnancy where the pregnancy hormone is detected in the bloodstream, but declines before pregnancy can be detected on ultrasound. You might also hear anembryonic pregnancy or blighted ovum, where there's a gestational sac without an embryo. In regards to categorizing by clinical presentation, you may hear threatened, missed, inevitable, incomplete, or even complete spontaneous abortion, depending on the symptoms a patient is experiencing or what we're seeing on ultrasound. So, a lot of different terms out there.

Host: And how common is pregnancy loss?

Dr. Meg Sax: Pregnancy loss is estimated to occur in one in four patients. Approximately 80% of all pregnancy losses actually occur in the first trimester. Unfortunately, pregnancy loss becomes more common with increasing age of the female. So at 20 to 30 years old, we typically say the risk of loss may be 10-20%, but this increases to 40% at 40 years old and 80% at 45 years old according to the American College of Obstetricians and Gynecologists.

Host: That is certainly different. So, what are some causes of pregnancy loss?

Dr. Meg Sax: The majority of sporadic losses, or about 50%, actually result from chromosomal abnormalities, or when the genetic material that forms the embryo comes together incorrectly. In recurrent pregnancy loss, when we find two or more failed clinical pregnancies, in addition to genetics, other causes may include uterine anomalies, blood clotting or autoimmune disorders, infection, sperm quality, and lifestyle factors.

Host: And how can recurrent pregnancy loss be diagnosed and treated?

Dr. Meg Sax: Recurrent pregnancy loss may be diagnosed once a patient has had two of those failed clinical pregnancies. And treatment largely depends on the underlying cause, but there are interventions that certainly can help if we are able to identify a cause. Unfortunately, 50-75% of patients with recurrent loss will not have a clearly defined cause for their pregnancy losses. But nonetheless, 50-60% may go on to have a future successful pregnancy, depending on the maternal age and parity.

Host: Okay. Well, that's hopeful. And now, this is personal for you, how can a reproductive endocrinologist assist couples who have experienced pregnancy loss?

Dr. Meg Sax: Absolutely. So, reproductive endocrinology and infertility specialists, or REIs, like myself, dedicate a significant amount of our training not only to promoting fertility and achieving conception, but to ensuring pregnancy loss is appropriately diagnosed, investigated, and treated when indicated. We approach every loss with compassion and help patients navigate options to safely pursue pregnancy and achieve their family-building goals.

Host: So, what role does genetic testing play in understanding pregnancy loss?

Dr. Meg Sax: It's important to distinguish genetic testing of products of conception, or the pregnancy tissue, versus genetic testing of the parents. In the event of a sporadic miscarriage, the pregnancy tissue can be tested to determine if there was a genetic cause, like too many or too few chromosomes, which we also refer to as aneuploidy, which is exceedingly common. But for couples experiencing recurrent loss, they may actually have their own chromosomes analyzed with a blood test to determine if they themselves have an abnormality that may be causing offspring to have irregular numbers of chromosomes that make developing a healthy pregnancy more challenging.

Host: Okay. Information is power. Are there any lifestyle changes that can help reduce the risk of pregnancy loss?

Dr. Meg Sax: Certainly, we see that cigarette smoking, obesity, drug use, and excessive alcohol and caffeine consumption can all lead to increased risk of pregnancy loss. It's also important to be up-to-date with general health screening because disorders like diabetes, high blood pressure, cardiovascular disease might go undiagnosed, and optimizing these disorders with a primary care doctor can help achieve a healthy pregnancy.

Host: You said excessive alcohol use. Can you be more specific about daily intake?

Dr. Meg Sax: Yes, I'm so glad that you asked. For women, we typically say this is more than three to five alcoholic drinks a week. And then, for caffeine, more than two to three cups of coffee a day or 200 milligrams of caffeine a day.

Host: How does age impact the risk of miscarriage and other types of pregnancy loss?

Dr. Meg Sax: As we mentioned, unfortunately, pregnancy loss does become more common with increasing age of the female. So again, I would say increasing to about 40% at age 40 and 80% at 45. There is some evidence to suggest that age of the male may also contribute to miscarriage with risk increasing around age 40 to 45.

Host: Interesting, because they usually, historically, got off the hook.

Dr. Meg Sax: Exactly. There's always been a lot of emphasis on the female counterpart, but we are discovering more and more each year.

Host: Okay. Good to know. What are some common misconceptions about pregnancy loss?

Dr. Meg Sax: I would say the number one misconception is, "I did something to cause this." So many patients will go down the rabbit hole of, "What if I didn't go on that work trip?" or "What if I had done more yoga?" or whatever it may be. While excessive stress is not beneficial to a pregnancy, it's not a direct cause of miscarriage. Unfortunately, as we've said, miscarriage is common and usually completely out of our hands.

Another misconception is the need to wait or have a few menstrual cycles before trying to conceive again. Following an uncomplicated early loss, it's okay to try to conceive again as long as the pregnancy has resolved, meaning there's negative blood and/or urine testing for that pregnancy hormone. But I do want to emphasize everyone is different and patients should do what's best for them. If waiting a few months to grieve the loss feels more appropriate, then absolutely take your time.

Host: Yeah. You got to set yourself up for success.

Dr. Meg Sax: Right.

Host: How can a couple prepare for a subsequent pregnancy after experiencing a loss?

Dr. Meg Sax: Maintaining good general health with a healthy diet, exercising, and optimizing any underlying medical conditions. But also, it's important in this process to be gentle with yourself and your partner and take time to grieve as needed. I would also encourage patients to seek out REI specialists. If they've experienced two or more losses or have family-building goals that may feel overwhelming in the context of their age. Or in other words, if a woman's approaching her late 30s or early 40s and may want three children, it might be prudent to consider proceeding with IVF for fertility preservation given the increased risk of miscarriage and decreased chance of natural conception.

Host: Let's talk about the horizon a little bit. And what advancements in reproductive medicine are helping to reduce the risk of pregnancy loss?

Dr. Meg Sax: Now, one of the most important advances is in vitro fertilization with biopsying embryos or something that we call preimplantation genetic testing to look for aneuploidy, those abnormal numbers of chromosomes. So in short, we call this IVF with PGTA. These results might be up to about 95% accurate in predicting aneuploidy in the embryo and provides patients who have experienced unexplained losses or history of pregnancies with chromosomal abnormalities peace of mind in knowing that the embryo that's been transferred to the uterus is likely chromosomally normal. Some studies have even suggested that testing the embryos prior to implantation in patients with a history of recurrent loss may improve live birth rate by 20%.

Host: Well, that's good news. Now, how can we raise awareness and reduce the stigma surrounding pregnancy and infant loss? And is there still a stigma?

Dr. Meg Sax: I would say there's certainly still a stigma, and the way to combat that is going to be by continuing to have discussions just like this. So if you've experienced a loss and you're comfortable sharing your story with your family and friends, I certainly encourage you to do so. I'm sure you'll be surprised how many people in your life have also had a loss.

Host: Yeah. You really spoke to me when you said, "Oh, it could have been my fault because I was doing the same thing and having trouble." And I went for a long hot walk in New York, when I couldn't find a cab and I was sure that it was my fault. I was sure it was that walk. So, we can't just point the fingers at ourselves all the time, right?

Dr. Meg Sax: And you are not alone. I will tell you, I hear that almost every day. And it's such a privilege to care for patients in such a sensitive and intimate part of their fertility journey. But that's the first thing I like to address with patients is there's nothing that you did here and future is bright.

Host: Your compassion is shining through during this interview, and I just want to thank you so much again for being here. Is there anything you'd like to add to our conversation?

Dr. Meg Sax: I just want to say it's been an honor to be here and thank you for putting together this so that we can show love and support to our patients who have had a loss.

Host: That is the plan. And thank you so much for your great information and all your care, Dr. Sax. Thanks for being with us to share your insights and your expertise.

Dr. Meg Sax: Thanks, Deborah. Take care.

Host: You can schedule an appointment to talk to a fertility specialist at 877-324-4483 or visit fcionline.com for more information. And if you enjoyed this podcast, you can find more like it in our podcast library and be sure to give us a like and a follow if you do. That's all for this time. I'm Deborah Howell. Have yourself a great day.