Melanie Cole (Host):  The US Department of Health and Human Services estimates that up to 5% of pregnant women may experience up to two consecutive miscarriages. My guest today is Dr. William Ziegler. He's a board-certified specialist in reproductive endocrinology and infertility at the Reproductive Science Center of New Jersey. Welcome to the show, Dr. Ziegler. So, women are so excited when they get pregnant. What do you see the most if a woman suffers a miscarriage? What's the most common reason?

Dr. William Ziegler (Guest):  Well, in most recurrent pregnancy loss patients, we can find an etiology for their losses in probably around 40% of the cases. In 50%, we cannot find a reason why. So, we have to just empirically treat them. But, we take a look at the statistics in which you just mentioned and we know that we know that up to 50% of all fertilized eggs do not progress and, basically, they undergo what is called a chemical pregnancy loss. When you take a look at the definition of recurrent pregnancy loss, you find many different definitions out there. The one that we kind of go by is that if somebody has had two documented pregnancies within the uterus that did not continue. This is when we start to intervene because we'd rather not have a couple go through a third loss because it does carry with it a lot of psychological baggage that can really affect a couple's relationship and their outlook on getting pregnant in the future. Up to 30% of pregnancies are lost between implantation and 6 weeks, so what we try to do is to identify causes that could affect implantation.

Melanie:  Are there certain risk factors? Is there a genetic predisposition to having miscarriages? Is age a factor? What about car accidents, things like that? Give us some of the risk factors and things that women should think about.

Dr. Ziegler:  I think the biggest one is maternal age. That as a woman does get older, we do know there is a higher risk of pregnancy losses. Over the age of 40, you're looking at close to 65-70% of all pregnancies are going to result in a loss within the first trimester. One of the major causes is basically genetics. Up to 70% of all early losses are due to chromosomal abnormalities and 30% of second trimester have abnormal chromosomes. So, these are some big issues that we try to identify. When we take a look at--you were mentioning before about car accidents--trauma, the actual statistics out on that are quite skewed. So, we do know that if somebody is in a car accident, they are at a higher risk for having a pregnancy loss if they're pregnant at that time. It also depends on where they are within the gestation.

Melanie:  Well, that's a good point. Is there a certain point in your cycle there--in your gestational cycle--that you're most subject to miscarriage and can a woman kind of breathe a sigh of relief once she's past, say, the first trimester?

Dr. Ziegler:  After we document a pregnancy in the uterus and we see heart motion, the miscarriage is down from, as I mentioned before, around 50%, down to around 20%. At eight weeks, if the pregnancy is progressing normally, and the heart rate is visualized, then the miscarriage rate drops down to 5%, and at 12 weeks, it drops down to 2%. So, after 12 weeks, your miscarriage rate is really 2%, except in those that have a history of recurrent pregnancy losses, then that number is a bit higher. That even after we see fetal viability via ultrasound, still the miscarriage rate is still around 20-25% when, in most cases, it would drop down to 5%.

Melanie:  Women have a little spotting, sometimes bleeding a little bit during pregnancy--all kinds of things happen--but one of the biggest fears is that miscarriage. Are there some symptoms that you want women to get themselves right into the hospital if they experience?

Dr. Ziegler:  If a woman is experiencing pain that's doubling her over, or bleeding heavier than a period, those are the big warning signs. We do get spotting in the first trimester. It is quite common. This is mainly due to implantation bleeding as the pregnancy is growing. It's invading a woman's blood vessels and can cause some spotting. Also, the uterus is very vascular and when a woman is pregnant, the blood vessels are larger, or are engorged with blood, so even bearing down to have a bowel movement or urination can break a blood vessel in the cervix and that can cause some spotting. Especially, and even if, the patient is having relations, that even that act can induce some spotting also.

Melanie:  Okay. So, are there certain activities that you tell women, “I would not like you to engage in this because it's going to put you at risk”?

Dr. Ziegler:  We always recommend that the women that come to see us are already at risk for having a loss; so therefore, what we try to do is, for those women that are very athletic, we kind of curtail their aerobic activity to where they can do just free weights or isolated muscle groups but aerobics like the treadmill, the elliptical, even I have some patients that like going to what's called "hot yoga”. I probably would not recommend that mainly because it does shunt blood away from the organs that don't need it, and since you don't use your uterus for aerobic activity, that blood gets shunted away from that organ and, therefore, we don't know the impact that really has. So, we kind of limit their aerobic activity.

Melanie:  What kind of treatments are available for women that have recurrent pregnancy loss or miscarriages? Is there a way to stop one once it's started?

Dr. Ziegler:  Well, I think we have to start looking at prevention and we take a look at a couple's history, smoking and alcohol use, and heavy coffee consumption are some red flags, also, that we try to address before they get pregnant. There are some endocrine issues such as diabetes, thyroid disease, which can actually cause a problem with ovulation. We take a look at a woman's uterus to make sure that it's not misshapen. Uterine septums are the most common anatomical cause of pregnancy losses and if we see that, then we can address it. We also check for infections such as ureaplasma, mycoplasma, chlamydia. There are some things that, some bacteria that can live in the cervix that can cause pregnancy losses. Also, there are some immunological causes, too, that can affect a pregnancy and we try to treat those. After we identify any reason for having a loss, we try to address it by either correcting an endocrine issue or even surgery, if it an anatomical issue. Sometimes, as I mentioned before, in 60% of cases, we cannot identify a reason why. So, we try to, then, improve on the egg quality. We try to improve on the uterine lining and some of the things we use for that are fertility medications. By using the fertility medications, again, it can help improve the quality of the egg a woman makes, the quality of the embryo, and also improve the endometrial receptivity of the implantation and then of this embryo. When a patient gets pregnant, we then put them on supplemental progesterone, just to keep the progesterone level high so their uterus doesn't start to contract so they don't have a problem. We take the progesterone deficiency that could cause a pregnancy loss out of the picture by supplementing them.

Melanie:  So, what do you tell parents, Dr. Ziegler, about this situation and giving them some feeling of hope that when they are pregnant and they get pregnant and they're so happy--about what they can do and to keep this pregnancy viable?

Dr. Ziegler:  Well, we kind of counsel all of our patients the same. Once they do get pregnant, we do stress the environmental issues such as smoking, and alcohol use and caffeine use and we want them to limit that as best as possible. With smoking, we'd like for them to cease doing that. We look at their activity. Again, we need to curtail any activities that would increase a heart rate that would cause shunting of blood away from the uterus. We, again, supplement them with progesterone to help them carry the pregnancy, and then, they can live their normal life and if they start having any problems, then they have to give us a phone call and then we can address them at that time.

Melanie:  Tell us about your team at Reproductive Science Center of New Jersey.

Dr. Ziegler:  Well, patients do see an individual physician; however, we do treat the patient as part of the team. We have physicians, we have physician's assistants, we have nursing staff, we have our front office staff and everybody knows the patient. We try to tailor their treatment to their needs. It's not just one physician looking at a patient's chart, but we have several physicians looking at a patient's chart, and we get input from everybody so we can better serve the patient and help them get pregnant quickly so they can move on with the next chapter of their life.

Melanie:  Thank you so much for the great information, Dr. Ziegler. You're listening to Fertility Talk with the Reproductive Science Center of New Jersey. For more information, you can go to fertilitynj.com. That's fertilitynj.com. This is Melanie Cole, thanks so much for listening.