Ep. 215: Treating complex recurrent pregnancy loss through restorative reproductive medicine, with Amanda Frederick, NP

One pregnancy loss is too many, but for those who experience it over and over again it’s a special kind of heartbreak. In today’s episode, Caitlin welcomes restorative reproductive medicine nurse practitioner, Amanda Frederick, back to the show to explore the complex and sensitive topic of pregnancy loss, focusing on recurrent miscarriage. We discuss: 

• The prevalence and emotional impact of pregnancy loss, especially for those trying to conceive
• The role of thorough history-taking to identify potential causes of miscarriage
• Causes of recurrent pregnancy loss, including genetic, structural, hormonal, autoimmune, and microbiome factors
• Knowledge about various tiers of testing, from hormone panels to immunology and genetic assessments
• How targeted treatment plans can improve pregnancy outcomes, including for women over 35
• Success stories demonstrating the effectiveness of personalized care and deeper investigation

NOTE: This episode talks openly about hard topics such as miscarriage and pregnancy loss. 

GUEST BIO: Amanda Frederick is a board-certified family nurse practitioner at Fiat Integrative Health in Franklin, Tennessee, with a practice focused on women’s health (NaPro Technology), breast-feeding medicine, and functional medicine.  Amanda especially values empowering women to understand their bodies and optimize them. She is especially passionate about optimizing thyroid function for fertility and treating and preventing recurrent pregnancy loss. 

Amanda lives in Williamson County, Tennessee with her husband David and their four children. 

SHOW NOTES: 

Fiat Integrative Health

Dr. Boyle's DHEA Research

Ep. 107: Reproductive Immunology & Pregnancy Loss, with Dr. Cynthia Mangubat

Ep. 26: Miscarriage 101

Transcript

Caitlin Estes (00:24)
Welcome back to the Woven Well podcast. We're gonna be talking about a sensitive topic today, but one that deserves attention and care, pregnancy loss. It is an excruciating experience for anyone who goes through it. But for those who are trying to conceive, 2.5 % may actually experience it more than once.

Any loss is heartbreaking, but experiencing it again and again, that is devastating. Especially when those trying to conceive feel like they don't have the knowledge or resources that they need to prevent future losses. So I've invited back Amanda Frederick from Fiat Integrative Health in Franklin, Tennessee. Amanda is an experienced nurse practitioner and a NAPRO technology medical consultant with a passion for treating thyroid and preventing recurrent pregnancy loss.

She's worked with many of my couples over the years and I've seen her handle delicate cases with expertise and wisdom. I'm excited for you to hear from her today. Amanda, welcome back.

Amanda Frederick, NP (01:23)
Thanks, Caitlin, thanks for having me.

Caitlin Estes (01:26)
There is so much that we can talk about, particularly about this topic. And I want to get every little bit of information we can out of our time. Because I know that those who are suffering from recurrent pregnancy loss are eager for any kind of support they can get. let's just imagine for a second that a couple has walked through your door and you sit down, start talking with them and they have experienced recurrent pregnancy loss. What would you do for a new patient like that?

Amanda Frederick, NP (01:30)
That's it.

Well, first off, I usually want to get a very detailed history about each pregnancy, how it went, the different details of what happened: if there were any genetic problems or structural problems with the uterus, known clotting disorders, autoimmune conditions, PCOS, endometriosis, that sort of thing. But I usually try to get to know the patient very, very well and take a history on each pregnancy. So we usually start with number one and go through all the details of what happened, how long gestation was, if things were spontaneous, because a lot of the details of the loss can tell us what direction to go with treatment.

Caitlin Estes (02:36)
Hmm. And that's so helpful too, because I think about how many times ladies are not really asked any information about a loss other than how far along it was in the end. So getting that full picture and learning a little bit more, I would think it's encouraging to the woman walking through it, the couple walking through it as well, knowing that that information may actually be helpful in preventing future losses.

Too often, I think people are told, things like this, they just happen. And that's a very defeating statement. I mean, it's encouraging to know that we as women are not causing the losses, but it also makes it seem like, well, there's not really anything you can do. It just happens and it's gonna happen again and again. Do you find that in your practice?

Amanda Frederick, NP (03:23)
I mean, that's usually what people have been told, especially if they've had just one loss. And we kind of take the approach that any loss of life that could be prevented is a tragedy. And while 50 % of miscarriages may be caused by chromosomal abnormalities, once you get beyond one loss and you're having a recurrent situation like this, it's likely there's something that could be prevented. Those chromosomal abnormalities, except in rare genetic situations, are not going to occur over and over again. And so we usually take a pretty aggressive approach, especially to someone who has had two or more losses. But I usually offer all the testing to one loss because, especially in the case of someone who's had genetic testing ⁓ after a miscarriage and they know they didn't have a chromosomal abnormality, there's really no answer as to what caused that and we can start down the road of answers.

Caitlin Estes (04:22)
Absolutely and there are ways to get that genetic testing done listeners you know you can either if you have a DNC sometimes you can request that genetic testing but also if you know ahead of time that you're going to have a loss you can actually arrange for genetic testing afterwards even if you have that loss at home is that the experience that you would talk through your patients with like how to advocate for that kind of testing as well?

Amanda Frederick, NP (04:49)
Typically, yes, especially in the case of D&C it's easy. know, the collecting at home, some people want to do it, some people are just traumatized by the situation and they don't want to, you know, add an extra step to it. But yes, ⁓ if it's possible, I think that's very helpful.

Caitlin Estes (05:04)
Yeah, I think sometimes just knowing that it's an option, then you have the choice whether or not you want to do it. But a lot of times people don't know that there is a way to still get that genetic testing done. But you do have to plan for it ahead of time. So absolutely. Well, I'm really encouraged already by hearing everything that you have to say. So let's kind of dive into what some of those main causes for recurrent pregnancy loss, maybe some that you especially see in your practice or just in general that listeners may not know about.

Amanda Frederick, NP (05:36)
Yeah, absolutely. So apart from chromosomal, I'm going to kind of leave that since we've already covered that that's about 50 % of losses. There's a whole host of different things that can cause miscarriage from: uterine defects like a uterine septum or a uterine ismosele, which would be a pocket in a C-section scar after a C-section history. There can be hormonal problems, low progesterone, low estradiol, thyroid disease, insulin resistance. And then you have things like autoimmune conditions and autoimmune clotting disorders, thrombophilias, which would be genetic disorders, where you have a gene that promotes clotting. That's something that comes up actually more often than you would think in my practice. And then you've got immunology issues like elevated natural killer cells or some of the more obscure testing that's done by like a reproductive immunologist like LAD testing. I've also come into contact with a lot of women who have an inflamed uterine lining, like either chronic endometritis or implantation failure that's caused by just an abnormal uterine microbiome. And so sometimes testing for that can be helpful in the evaluation of miscarriage. There's of course genetic disorders that can cause miscarriage and endometriosis is another one that can sometimes cause miscarriage as well.

The male part in miscarriage is still debated, but DNA fragmentation has been the topic of several conferences I've been to recently where the male genetic material might be contributing as well to miscarriage.

Caitlin Estes (07:27)
That makes sense. mean, it's half of the DNA. It's very important. It makes sense that it could. Wow. So everything you just said, I'm just thinking about how different it is from that platitude that women and couples are so often told that we just can't know why these things happen. And you've just given a very long and thorough list of just the categories of things that could potentially cause a loss. So the follow-up question to that is, okay, there are all these possibilities. How in the world do you go about determining which of those may be caused a loss? And then are there actually treatment options for them? Is it IVF? Is that needed? What's kind the next step? So diagnosing and then treating, what are our options there?

Amanda Frederick, NP (08:17)
Absolutely, and that's going to be kind of a long drawn out explanation because there are a lot of options. I lean towards not doing any testing that I don't have a treatment for just because it tends to spend funds and it doesn't get you anywhere. So you can do very detailed genetic testing to see if there's recessive genes from either the mother or the father that are causing genetic disorders. But that's the one thing that you can't change if that's happening over and over again. It's just a trip to genetic counseling and hope for the best. And so I don't typically push people towards that ⁓ workup because it's not going to really yield anything. So I usually do the things that could actually change the outcome.

So the pregnancy history is really, really helpful in deciding are these losses occurring all at the same time gestationally, which would indicate that maybe something is awry that is ending the pregnancy at the same point each time. Is there a C-section history? Of course, then I might worry about structural issues if there's been a C-section history, other complications of pregnancy. If I have a mom who has had gestational diabetes every time, but she's not being treated for insulin resistance, I usually assume that we probably need to treat insulin resistance before we move on in this fertility journey. But right now, the minimum workup according to up to date is to do a saline infused ultrasound with two or more losses, an antiphospholipid syndrome test, some basic thyroid testing, and then of course the testing of the fetus and the father if you're able to get products of conception. To me, that's typically not enough, especially for people who have had multiple losses and losses that don't have any explanation. So typically I divide my testing up into tiers, and this is because when I see people, I want them to know all the options. I never want a patient who's had a miscarriage to say to me, well, Amanda didn't tell me that this was an option. So I want them to know what their options are, but they don't have to choose all the options. In fact, I will even encourage them not to. If it's been one loss or two losses, we don't need a $5,000 workup necessarily, but I want them to know what their options are. So if there's...

Caitlin Estes (10:29)
Mm. Mm-hmm.

Amanda Frederick, NP (10:46)
A strong indicator in the history that there's a structural issue like a uterine ismaceal or septum, I will send for saline-infused ultrasound at the beginning of their cycle to evaluate that. And we have some great restorative reproductive surgeons who are specialists in especially removing ismaceal and removing uterine septum as well. So that's a nice thing that we have in our community. But I usually always start with what they call tier one testing, which is your hormones. I do them between peak plus six and nine of the cycle. We'll do testosterone, DHEA, progesterone, estrogen, prolactin, all the thyroid hormones, a full thyroid picture, not just your TSH, definitely TPO antibodies to check for Hashimoto's and an insulin resistance evaluation. So that's kind of baseline. I do require that for everybody. But beyond that our tier two testing is the antiphospholipid syndrome, which I definitely encourage for people who have had two or more losses. Tier three is thrombophilias, and we add some thrombophilias that are a little bit more obscure. So there's the really important ones, like antithrombin activity, prothrombin, and factor V Leiden. But then there's some more experimental ones like MTHFR and the PAI, 4G, 5G polymorphism, and several others. And I usually give them all of these options. I've definitely seen these play out in pregnancy before and so I do believe that they play a part in miscarriage and so we usually do talk through which are the most important especially if finances are concern. Then my tier four is the immunology testing which dives a little deeper into what might be able what might be happening on an immune system level.

Caitlin Estes (12:28)
Yeah.

Amanda Frederick, NP (12:39)
And of course, kind of ancillary things are endometriosis or uterine microbiome evaluation and endometriosis evaluation and kind of the worst case scenario.

Caitlin Estes (12:50)
That's so thorough and I would imagine maybe a little overwhelming but also very encouraging because certainly with all of that we can actually get to that underlying cause of what's causing the losses which then we can actually do something with that. So the fact that you said that you don't test for anything that can't be treated all of those things have a treatment and that's so encouraging.

I know that in my client population, I've had a lot of ladies who in the past experienced loss and were told, hey, if you do IVF, you're less likely to have loss. And that may or may not be true with ⁓ different people and their underlying issues. But if we don't ever treat the underlying issue, then the losses may continue on. And here are ways to be able to figure out what's causing that loss, address it specifically and then hopefully conception can happen on its own but also that pregnancy can go to full term prayerfully that is the goal. And now you've mentioned that you do offer all of this testing after even one loss. I'm just kind of curious is there ever an instance where you would recommend this type of testing even before pregnancy occurs like as someone is trying to conceive or just thinking about it or is that kind of like overboard?

Amanda Frederick, NP (14:11)
I wouldn't offer all of it, I don't think, for any reason before, but there are special situations like women over 35 or those who have known hormonal problems or family history. I've definitely had some people have come to me with a pretty strong family history of deep vein thrombosis, strokes, where the thought is there must be some type of genetic element here. It would be good to check this before pregnancy, before it plays out in pregnancy. Same way with people with known autoimmune conditions. A lot of times if they're coming to me for fertility evaluation or even just like pre-marriage fertility help, I do dive a little bit deeper into the immune system issues right away.

Caitlin Estes (14:57)
And you mentioned your client population in particular and how you've seen some of these things play out in pregnancy. I'm curious, are there maybe even less common causes for recurrent pregnancy loss that you see more frequently in your client population? Like things that we think aren't all that common or, that's not gonna affect me, but actually you see it kind of frequently.

Amanda Frederick, NP (15:22)
So yes. I think one, and this one is becoming, is definitely coming to prominence in the restorative reproductive community is low estrogen in pregnancy. And now that Dr. Boyle's paper has been published and there's good information about DHEA use in pregnancy, I started using it about a year and a half ago, and that has just come up over and over again, especially in my recurrent pregnancy loss patients who are in their early 40s. And we've been able to save a lot of pregnancy just by watching those estrogen levels and treating them. And pregnancies of people who've had three plus losses and now they're able to carry a baby at the age of 42 because they took DHEA in pregnancy.

Caitlin Estes (16:07)
So encouraging and I if you have any I would love to hear maybe some of the clients that you've worked with anonymously and just how have you seen this play out in your own work?

Amanda Frederick, NP (16:20)
So I've definitely taken care of some patients where we really have to deep dive into all the different issues. I had one and this is one that probably is just a good demonstration of looking deeper and deeper. We had a patient who was 38 years old, had been pregnant twice, two losses in fertility history, knew she had Hashimoto's and she had been seeing another fertility provider for years and had been prescribed her levothyroxine and letrozole and she'd already had a laparoscopy so there wasn't a whole lot to do surgically. And we just kept digging and she had really high thyroid antibodies so we decided to try some of the new protocol for using hydroxychloroquine with people with high antibodies. And then she had one marker of antiphospholipid syndrome but not the actual syndrome.

But we decided, you know what, we got the hydroxychloroquine, let's go ahead and add aspirin. And we ended up doing lovinox as a thing we would add if she became pregnant. We started metformin for insulin resistance, high dose progesterone, DHEA. She ended up being on HCG injections in the luteal phase. And after years of infertility and miscarriage, she did conceive. Now it was a high risk pregnancy. It was a lot of work. But it worked out and it was her first pregnancy to go beyond the first trimester and she's due I think in a couple of weeks. So it's really, really exciting to be able to see that and it just meant digging deeper and not taking no for an answer. Like we couldn't find something at first, but we just kept digging and we have a good outcome.

Caitlin Estes (17:56)
Hmm. Praise the Lord. That's awesome. That's really amazing. You mentioned earlier clients in their 40s and I love that you just said that offhand because so many ladies and couples in general think, well, all of this applies to those who are in their 20s or their early 30s, but you know, I'm over 35. So it's, you know, the work is going to be too much, and the success stories don't really include ladies over 35, but that's really not the case.

Amanda Frederick, NP (18:32)
No, not at all. I've had some really amazing success stories of people in their early to mid 40s getting these issues taken care of and having successful outcomes.

Caitlin Estes (18:43)
Beautiful, wonderful. Well, I know our time was short, but thank you so much for coming back and talking about this really important issue. We're so blessed to have you as our medical consultant at Woven.

Amanda Frederick, NP (18:54)
Absolutely, it's my pleasure. Thanks, Caitlin.

Caitlin Estes (18:57)
Listeners, if you're in the Tennessee or Missouri area and would like to work with Amanda at Fiat, check out the show notes to get a link to her practice. While this medical guidance is essential for any couple struggling with pregnancy loss, I want to acknowledge that it's more than physical too. The pain of losing a child is tremendous and it affects you at a deeply, personal level. Physically and medically, yes, but also mentally, emotionally, spiritually, even relationally. In my opinion, these are just as important as the physical side and deserve equal care and support. So if you'd like resources for prayer, mental health counseling, or other support you think we can help, send us an email at hello@wovenfertility.com. As always, thanks for listening as we continue to explore together what it means to be woven well.