Ep 305: Why Am I Having Miscarriages: A Deep Dive into Recurrent Pregnancy Loss

 Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, the docs welcome visiting physician Dr. Shelley Dolitsky from Shady Grove Fertility in Towson, Maryland, for an in-depth conversation about recurrent pregnancy loss. Dr. Dolitsky begins by reviewing how different professional organizations define recurrent pregnancy loss. The American Society for Reproductive Medicine considers two or more losses—including very early biochemical losses—to be recurrent pregnancy loss, while the American College of OB/GYN defines it as two clinical losses under 20 weeks. The docs discuss how age dramatically affects miscarriage risk, with up to 75% of women over 40 experiencing miscarriages, compared with an overall rate of three to five percent. They walk through the full evaluation, which includes assessing the uterine cavity for abnormalities such as scar tissue, polyps, or congenital malformations; ensuring the fallopian tubes are normal and ruling out tubal damage; and performing chromosome analysis on both partners. Testing for antiphospholipid antibodies and lupus anticoagulant is also essential, as these can contribute to placental clotting issues. The conversation highlights the importance of screening for chronic medical issues that might be undiagnosed. About half of patients with recurrent pregnancy loss will have an identifiable and often treatable cause. Finally, the team discusses recommendations for patients whose workup is normal but who continue to experience losses. This podcast was sponsored by Shady Grove Fertility. 

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Carrie Bedient MD (00:22)

Hello and welcome to another episode of Fertility Docs Uncensored. I am Dr. Carrie Bedient from the Fertility Center of Las Vegas and I am joined by my two vibrant, vivacious co-hosts, Dr. Susan Hudson from Texas Fertility Center and Dr. Abby Eblen from Nashville Fertility Center. And we are joined today by Dr. Shelley Dolitsky, who is an REI from Shady Grove Fertility in Maryland. And we are delighted to have you with us today, Shelley.

Shelley Dolitsky MD (00:53)

Thank you so much for having me. I'm delighted to be here.

Carrie Bedient MD (00:56)

So we were talking a little bit beforehand, and you had mentioned that you are a voracious reader. And so the question for you for the day, for sure, which I'm actually super excited to hear the answers to, what were your top reads of 2025?

Shelley Dolitsky MD (01:15)

That's a great question. I have to think back. I read about, I would say, a book a week. So we're in December. So I definitely am not going to be able to remember every book I've read. But the last one that I really enjoyed actually was The Housemaid. It's not my typical genre, I would say, but once I find out a movie is coming out, I have to read the book first. So the movie is coming out next week. So I had to read it. And I loved it.

I read a lot of books and so typically about 25 % of the way and it can sense where it's going, which I don't mind. I love surprises. And this book actually really took me by surprise. I did not see the twist coming at all. I finished it in two days, which is pretty quick for me actually. And that was great. I would say my typical genre though, it's more like Kristin Hannah, The Women recently. I really liked that one.

And then like The Wedding People, I can't remember, Alison something wrote it. Yeah, I love that one too. So more like women's fiction.

Carrie Bedient MD (02:12)

That was a good one.

Abby Eblen MD (02:12)

Atmosphere, have you read that? It's good.

Shelley Dolitsky MD (02:19)

That's on my list. That's on my list. Yeah, I just that came out recently. It's like Taylor Jenkins Reid, I think is that one. Yeah, it's on my list. I like her a lot.

Abby Eblen MD (02:24)

Yes, I love all of books, yeah.

Susan Hudson MD (02:28)

I really think it's fantastic how really I think in the last five, 10 years there has become more and more literature really aimed at women. I mean, it's just, it's fantastic and it's so fun and I'm a listener. I'm not a reader, but I'm in my car a lot. I don't go through books nearly as fast as you do, cause I'd have to have them on fast forward and that kind of drives me nuts, but that's awesome.

Susan Hudson MD (02:56)

That's so, great, it's a great pastime.

Shelley Dolitsky MD (02:58)

Yes, I love audiobooks also. Actually, Julia Whalen, she's one of the big audiobook narrators and I basically will read anything she will read. I guess or narrate.

Carrie Bedient MD (03:09)

Yeah, that's awesome. All right, well, we'll have to put some of those on on our to be read lists for this upcoming year because it's always it's always nice to get a set of books that will be helpful and just an escape from everything else. And thank you. Thank you for the recommendations. Thank you for the recommendations.

Susan Hudson MD (03:37)

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Carrie Bedient MD (04:59)

All right, Susan, do we have questions for this week?

Susan Hudson MD (05:04)

We do, we do. Our question for this week is, I 40, husband 45 have been trying to conceive for a year. We established with an RE, had a workup and are doing IVF due to age and male factor infertility. Since my IUD was removed, I've had irregular cycles 25 to 50 days. I track cycles with LH strips and if it rises, it's variable as to when.

My follicular phases range between 15 to 30 days and luteal is always 12 to 13 days. Periods are normal. I am lean with no hirsutism, diabetes, et cetera. AMH 10 months ago was 6.7 and RE repeated it now and it was 3.2. AFC is 21. Rest of labs along with HSG and SIS are normal. I've been on birth control for 20 plus years so I don't remember when I was younger. Do I have PCOS or are the irregular cycles normal at 40? If not PCOS, what causes irregular cycles at 40? RE says it's just due to age.

Abby Eblen MD (06:01)

It may have been the way she was from the very beginning, she just doesn't remember that. At first I thought when we based on her age, I thought it was decreased ovarian reserve. I'm like, she's 40. But with an AFC count of 21 and an AMH of 3.2, I don't think it's decreased ovarian reserve. I kind of think that's maybe the way she's been. She didn't mention her weight though, because weight can make a difference. Oh, lean. Okay. I would bet that's the way she's always been.

Susan Hudson MD (06:02)

She says she was lean.

Carrie Bedient MD (06:26)

Yeah, I think lean PCOS is a pretty decent guess. Who knows what the androgen levels are? Who knows if there's any hirsutism? So hair growth, acne, anything like that, they would indicate high androgen or male hormone levels. But even without those things, ovulatory dysfunction is real. And well, yes, PCOS has a very typical, footprint presentation that it shows up with.

Typical doesn't mean always. And we can see people who you would never guess in a million years until you really dive into their details that they have PCOS and then come to find out their cycles are really irregular and there's tip-offs here and there, insulin resistance. That can be something that even lean people can have, and it sounds like lean PCOS is a reasonable estimate. That's a much better problem to have than really decreased ovarian reserve from aging.

I'll take it, even if we don't have an exact diagnosis, I would much rather take your picture than many others.

Susan Hudson MD (07:25)

An important thing though is even though your quantity of eggs is absolutely phenomenal for 40, don't delay treatment and really think about how many children you want to have because if you're wanting to have more than one, being more aggressive and thinking about something like IVF might behoove you just because in about half of IVF cycles in this type of situation, you're going to have embryos remaining that you may be able to use in the future. And however hard it is to get pregnant at 40 when you're 42, 43 and thinking about another baby, it's going to be even harder. And even though you have a lot of them, a lot of eggs, that doesn't mean they're of good quality because your eggs have been around for a year longer than you have. And that aging in quality is very, very real.

Carrie Bedient MD (08:18)

Absolutely.

Abby Eblen MD (08:18)

One other thing too, just to add on, and I'm sure her doctor has probably already checked this, but if they haven't checked your thyroid, you probably want to check that too, but it sounds like she's already been worked up and her doctor just thinks it's related to age.

Susan Hudson MD (08:31)

Shelley do you have thoughts?

Shelley Dolitsky MD (08:33)

I see this a lot where patients don't actually know if they have irregular cycles or not. They've been on contraception for a long time, whether it's birth control pill or an IUD, maybe they started it as a teenager.

We all know that irregular cycles as a teenager for the first couple of years can be normal. And if they started on contraception around that time or they don't remember, and then all of a sudden they stop their birth control. The question is, is this new or has this always been occurring? And I would say similar to what you guys said with her antral follicle count and her AMH, this does seem more in line with PCOS to me.

Carrie Bedient MD (09:06)

Absolutely. Okay, so let's Let's into our topic today, which this one always is of great interest to patients and listeners, and it's RPL, which is recurrent pregnancy loss. Shelley, what's the current going definition of recurrent pregnancy loss? What does that mean, and how does someone know if they may fall into that particular diagnostic bowl?

Shelley Dolitsky MD (09:31)

Yeah, that's a great question. The actual definition of recurrent pregnancy loss is two pregnancy losses, less than 20 weeks gestation. And the definition really includes clinical pregnancy loss. So there has to be some clinical sign of pregnancy, like seeing a gestational sac or a crown rump length a fetus on the ultrasound. That's the true definition of recurrent pregnancy loss. Although, in practice, we include a broader range. We'll include things like biochemical pregnancy where people had a positive pregnancy test and then it was negative. And we start the evaluation a bit sooner for most people, but the definition would be two clinical pregnancy losses, less than 20 weeks gestation.

Carrie Bedient MD (10:16)

And why is it two rather than just one? Because so many patients come to us after one loss absolutely freaking out, super anxious. Oh my god, why did I lose this? Da da da da da da. And you can feel their energy. It's just absolutely palpable when they come through of the anxiety. But why does it take more than one to start this evaluation?

Shelley Dolitsky MD (10:25)

This is something I always say to patients is that pregnancy loss at any stage is devastating. And even one miscarriage, one biochemical pregnancy loss, a positive pregnancy test that was negative is heartbreaking and awful. And I certainly don't take that lightly. However, it's not medically concerning. My red flag doesn't go up at one miscarriage because in general, about 25 % of pregnancies will result in miscarriage and that number goes up with age. So at the age of 40, it's almost as high as 75 % of pregnancies will result in miscarriage and that's just based on age. If someone comes in and they're 40 years old and they've had one miscarriage, probably it's because it was an abnormal number of chromosomes, it's a normal medical phenomenon and it's something that we see all the time and it's not medically concerning.

That's not to say it's not emotionally devastating. It's just that we don't really start to worry that there's something else going on until two. Because statistically speaking, two miscarriages, two clinically recognized miscarriage only happens in about three to 5 % of women. That's much more rare and that certainly is worth investigating at that.

Carrie Bedient MD (11:57)

And do you happen to know off the top of your head, I do not know this off the top of my head, how the biochemical plays into this? Because you were talking about how it needs to be clinically seen, which is typically the crown rump length, gestational sac, something where you can see on ultrasound. But do you guys happen to know where biochemicals fit into that?

Susan Hudson MD (12:21)

Actually it depends on whose guidelines you're looking at. If you're looking at the American Society of Reproductive Medicine, which is what we usually hang our hats on, that clinically recognized part has been dropped from the committee statement. And it doesn't really cover any more what exactly qualifies. However, I believe the definition, possibly by ACOG, the American College of Obstetricians and Gynecologists is the one that includes clinically recognized. I also think this plays into why recurrent pregnancy loss is often treated more aggressively by reproductive endocrinologists as compared to OB-GYNs because we see people all the time that have had biochemicals and I can think of a number of those people. Those are the people that I think I'm more likely to pick up a chromosomal abnormality in themselves.

Shelley Dolitsky MD (13:26)

Yeah, I think also the biggest thing about the differences in the definitions is obviously, I always start my evaluation at two, any type of pregnancy loss. ASRM did recently change their guidelines, but when I counsel patients about the statistics, the, the three to 5 % chance of someone having two miscarriages, that is from the definition of clinical pregnancy loss.

Shelley Dolitsky MD (13:48)

I think the number of people having biochemical pregnancy losses is probably much higher. And we actually don't have good counseling for that. I don't always have a good number to tell people like if they had two positive pregnancy tests and two late miscarriages. All of our studies, for example, if you've had two clinical pregnancy losses, the chance of another one is about 25%. If you've had three, the chance of another one is about 27%. Like I have those numbers ready to go. I don't know that's, from the clinical pregnancy loss studies. And so it's a little bit harder to counsel people with biochemical pregnancy loss. I agree, it's still, we pick up things, we find things for sure. But I think that bucket is probably much bigger actually.

Abby Eblen MD (14:21)

And Shelley for our listeners, why do you think it's harder to counsel about biochemical pregnancies opposed to clinically recognized pregnancies?

Shelley Dolitsky MD (14:35)

Well, clinically recognized pregnancies, have a lot more data. So a lot of times if a patient gets a D&C, we can actually remove the products of conception and test them. I can tell you, and I have many, many patients who I can say, this was an abnormal pregnancy. This patient, your pregnancy was trisomy 16. It had three copies of 16. And I explain how that comes to be and what that means. And that...is not a predictor that that's going to happen in the future. That's more likely related to age. And if they have a normal embryo, like they've had a pregnancy, they had a heartbeat, they have a miscarriage, I do a D&C, I get a normal embryo, that's a really different evaluation entirely. And that's much harder to navigate someone who has a normal pregnancy and can't keep it.

Susan Hudson MD (15:18)

What are some of the things when you have somebody come in with recurrent pregnancy loss? What are parts of that evaluation?

Shelley Dolitsky MD (15:28)

I think of this in a very stepwise manner. The truth is I'm doing all of it at once, because they come to see me and I write everything down for people. I'm a very visual person and also I'm chatty, so it keeps me on message. But I, write it out. The first thing is we're looking for an evaluation of the uterine cavity. Is it able to hold a pregnancy?

I do something called a saline ultrasound where I get a really good look inside the uterine cavity. And that is basically a regular vaginal ultrasound, but we first put a little bit of saline inside the uterine cavity. And we're looking for things like polyps, scar tissue, fibroids, septums. So a septum is actually a congenital anomaly that you had been born with, but you really wouldn't know because it hasn't affected you until now. That's something we also look for.

Susan Hudson MD (16:16)

Why do you choose to do that saline ultrasound as compared to a normal transvaginal ultrasound?

Shelley Dolitsky MD (16:22)

The transvaginal ultrasound can definitely miss things. I explain this to my patients, your uterus is together. And so if there's a little bit of scar tissue, if there's a thin septum, you're not really gonna be able to tell. If there's a giant fibroid, we'll be able to see that. Or if there's a big polyp. But the saline actually gives us a really good view of very small abnormalities inside the uterus. And it really highlights everything that's going on.

That's my first choice for a uterine cavity evaluation for recurrent pregnancy loss.

Carrie Bedient MD (16:52)

The way that I explain this to my patients and Shelley, Susan and Abby are forever laughing at me about my analogies. So feel free to join in. But I always tell my patients that a normal vaginal ultrasound is like looking at the side of a peanut butter sandwich. You can tell that there's peanut butter there. You have no idea if it's crunchy or smooth. So when you put the saline in, it's like peeling the pieces of bread apart. At that point you can see, are there nuts in there or are there no nuts in there? It exposes it much more than you would otherwise see with just your side view of your peanut butter sandwich.

Abby Eblen MD (17:23)

Okay, let me just say this, Carrie, I've never heard that analogy, I've heard lots of your analogies, but I love that, that's great. ⁓

Susan Hudson MD (17:29)

That's a good one.

Shelley Dolitsky MD (17:31)

I use peanuts a lot when I talk about antral follicles and how they have eggs in them, like the eggs are microscopic. So I say it's like a peanut M&M. I can't see the peanut, but I know it's there. I also like to use my food analogies.

Carrie Bedient MD (17:43)

I like that. Yay! I have someone else who will destroy people's lunches and favorite snacks in the same way that I do. This is amazing. Okay.

Shelley Dolitsky MD (17:49)

Yeah, yes. I mean, it's the best way to visualize things.

Everyone loves peanut M&Ms.

Abby Eblen MD (17:55)

Yeah, that's true.

Carrie Bedient MD (17:55)

It's true, it's true. Although peanut butter M&Ms in my mind are superior. Susan, don't look at me in that tone of voice. Yeah, yeah. Okay, anyway, so we were talking about structural abnormalities in ultrasounds and their relationship to our favorite snacks. Anyway, saline ultrasound, how else do you look at the inside of the uterus? If you have any suspicion that, hey, this is not quite normal.

Abby Eblen MD (17:59)

⁓ I love them all. They're all great.

Shelley Dolitsky MD (18:03)

I do too, I love them all.

Carrie Bedient MD (18:22)

What happens next? How do you think about that? How do you approach it?

Shelley Dolitsky MD (18:25)

Yeah, so the next step would be to do what's called a hysteroscopy. We do this a lot in our practice. We have our surgery center. I work in Towson, so my office is on the sixth floor and the surgery center is on the first floor, which is actually very convenient for me. We basically put a camera and we put it inside the uterus. Our camera scope is five millimeters. It's half a centimeter. It's very small.

We go in with our camera so we can diagnose, we see like with our own eyes exactly what's going on. And then right through the camera, we can actually put our instruments so that we can diagnose and treat at the same time. That way, if there is a septum or big fibroid or polyps, we can remove it. We also just get a sense of what the uterine cavity looks like. As REIs we've seen a million inside of a million uteruses. So when I go in and something looks off, even it's not a polyp, but it's just like very red or looks kind of ugly. That's worth investigating and looking with your own eyes is always a great option.

Susan Hudson MD (19:25)

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Susan Hudson MD (20:03)

It's also important to perform an HSG or the hysterosalpingogram, the dye test of the fallopian tubes. This is usually the test that we get the most kickback from patients not wanting to do because they're like, why do I need to do this test? At least one of my tubes is open because I'm getting pregnant. But the important thing to understand is that open tubes does not necessarily mean healthy tubes. And what we're really looking for is a situation that's called a hydrosalpinx or a swollen fallopian tube, because people can have swollen fallopian tubes and them still be open. It doesn't mean you can't get pregnant, but it does mean that the architecture of the tube is abnormal. And that fluid within the tube can be bad and go back into the uterus and it's called embryo toxic where it can stop a developing pregnancy.

The other thing to know is that you could be at an increased risk of ectopic pregnancies, which are pregnancies in the wrong place. And as another little side rail comment, I do think it's really important when we're talking about recurrent pregnancy loss. I had a patient just a couple of weeks ago who had had, I think four or five quote miscarriages, but except for one that was clinically recognized in the uterus, these were all biochemical pregnancies or pregnancies of unknown location, they had hormone levels that went up, hormone levels that went down. And we all like to think that all of those happened in the uterus, but some of those could have been self-resolving ectopic pregnancies. So that's something else we have to keep in mind that just because you're having pregnancy loss, we can't be like, ⁓ they truly are just miscarriages even though it's not just for anybody, but we get worried when we're talking about ectopic pregnancies because that can be a life-threatening condition.

Shelley Dolitsky MD (22:02)

Yes.

Certainly. When I talk to my patients that recurrent pregnancy loss, we start with the uterus and the uterine cavity evaluation, then we talk about the flow pain tubes. And just like you were saying, got to make sure you don't have anything that's leaking toxic fluid. And then I go on to talk about the eggs and what could potentially be wrong there. And this is the way I describe it to patients in general is your eggs have been living in your body, just like the thing you said, Susan, for a year longer than you have. So every cell in your body, including your eggs, has 46 chromosomes in them. And when your egg is finally chosen to ovulate after 40 years of being in your body, it has to kick out half of the 46 chromosomes to make room for the sperm. And as we age, that gets harder and harder and harder to do. And that's true for everyone.

That could potentially be a cause of loss. And a lot of losses are just because you have that abnormal number of chromosomes. It's kicked out 22, because it got sticky and it didn't kick out the full 23. Then there's another step that's a little more complicated. And we talk about the possibility of what's called a translocation, which is where you actually have an abnormal, yourself have an abnormal chromosome. And so we'll do chromosome testing for both partners to look at the chromosomes called a karyotype. And we make sure that you actually have those 46 chromosomes that I'm telling you you have in this analogy.

Susan Hudson MD (23:23)

And those chromosomes are super important to get even if you have had children in the past. That's because you have living children, either partner does not eliminate the risk of you having a translocation.

Shelley Dolitsky MD (23:38)

Absolutely. Yes.

Although I recently had a patient, she had three pregnancies, successful pregnancies with her first partner. And then she had six miscarriages in a row with her second partner. And I was like, he has a translocation. Let's get him in here. Cause that really felt like a red flag. I mean, the chance of miscarriage with a translocation can be like 70%. So that's really high.

Abby Eblen MD (23:53)

Red flag there, right? Yeah.

Shelley Dolitsky MD (24:05)

Certainly you can have healthy pregnancies if you're very lucky, but it's really, that was a big red flag for me. Cause that's a high chance of miscarriage.

Carrie Bedient MD (24:14)

So what's some of the other laboratory evaluation that you do? We've talked about the structural stuff, some of the imaging and more invasive involved testing that we do. What's the most laboratory evaluation besides the karyotype that can be helpful in identifying a cause?

Shelley Dolitsky MD (24:19)

Absolutely. One of them that we'll do is called antiphospholipid antibody syndrome, which is we're really looking for a blood clotting disorder. This is very important because not only can it cause recurrent pregnancy loss and miscarriage, but it can also cause very high risk pregnancies. So patients can get pregnant successfully with this but then go on to have a preterm delivery because of severe preeclampsia or intrauterine growth restriction. It's really issues with the blood clotting, placentation, that kind of thing. That's really important to rule out. And then other things are really health related. People who have uncontrolled diabetes and don't realize are at much higher risk of miscarriage. I had someone recently who had a miscarriage. We checked the products of conception. She had...a normal embryo, and we were trying to figure out what's going on, and her hemoglobin A1C was eight. And she had no personal or family history of diabetes. She didn't know she had diabetes. And this isn't something I routinely test in patients who don't have her own pregnancy loss and don't have irregular cycles. It's not in my list, but that certainly can cause a miscarriage. So we check diabetes, I check thyroid function, and just kind of overall prenatal labs.

Susan Hudson MD (25:42)

What do you think about checking ovarian reserve in people with recurrent pregnancy loss?

Shelley Dolitsky MD (25:48)

Certainly, I check ovarian reserve testing more because if they have something that is going to require IVF, then we need to know how they're gonna respond to IVF. And I don't want to skip a step, skip the ovarian reserve testing, find out they have a translocation that we can fix, overcome potentially this translocation by doing IVF with genetic testing, and then not be able to tell them how they're gonna do in an IVF cycle, because I didn't do the ovarian reserve testing.

I do think that it's very important to have that knowledge for future counseling when you're trying to decide on a treatment plan.

Abby Eblen MD (26:23)

And on that same note, if somebody comes and goes, I think somebody had a clotting disorder in my family. Can you test me for clotting disorders?

Shelley Dolitsky MD (26:29)

Yeah, outside of antiphospholipid antibody syndrome, the rest of the clotting disorders are really not recommended to be tested. They're not found to be related. Now, if they have a family history of clotting, I'm gonna be sending them to their primary care doctor to be worked up for a clotting history or to, know, if that's something they need, certainly, because that's important for their overall health and, you need to be healthy to have a baby. But no, that's not something I would...put together with a recurrent pregnancy loss workout.

Susan Hudson MD (26:59)

I agree with that for first trimester, which is 95 % of the people that we end up seeing. In the very, very small percentage of people who have had history of second or third trimester losses, I would do a thrombophilia evaluation. But again, second and third trimester miscarriages or pregnancy losses if they're third trimester are very, very, very rare.

And so the vast majority of people listening are really going to be focusing on the first trimester, which I completely agree with.

Shelley Dolitsky MD (27:33)

Yeah. And especially third trimester losses. Trying to navigate what caused the third trimester loss is always a little bit more complicated. And I will say when I have patients with that, I usually speak to their MFM, see what they think could potentially been going on. Did they have any abnormal ultrasounds? Was there a clot found? And definitely go down there.

Abby Eblen MD (27:50)

Plus with that group too, they're probably gonna need additional monitoring when they're pregnant and all that kind of stuff too. It's always good for them to touch base with an MFM.

Carrie Bedient MD (27:57)

Yeah. How do you counsel on percent of patients where they've got this history and we actually find a reason for what's going on? If you have someone who comes in with this history, do you say, 100 % of the time, we're gonna find out the reason.

Shelley Dolitsky MD (28:21)

No, I usually say that it's about 50-50 if we're gonna find something. And for some reason, I know that the numbers are 50-50, but for some reason, and I think it's because I include biochemicals in my evaluation, I would say for my personal practice, it's more than 50 % of the time that I don't find anything, especially if a patient has had two biochemical pregnancy losses.

I almost never find anything and then usually they'll go on and have a healthy pregnancy the next time. I still do the entire evaluation and I use 50-50 for everyone because I think that's typically the correct answer. But I have found that with two biochemical losses for my practice, I find much more often that I don't find anything.

Carrie Bedient MD (29:05)

Mm hmm. When you have done this whole evaluation, how do you treat these things? So let's say you find the karyotype abnormality with a balanced translocation, or you find the bad thyroid or the antiphospholipid antibody syndrome, how do you approach these?

Shelley Dolitsky MD (29:09)

So each one of them is completely different, which is why it's so important to do a workup because we don't have one answer for everything. So for example, if you have antiphospholipid antibody syndrome, then the treatment for that is the blood thinner, which is called Lovenox and paired with aspirin and also follow with an MFM for your pregnancy. So that's something that's very important.

If there's obviously if there's any uterine abnormality, it's going to be fixed uterine abnormality. If there's going to be a hydrosalpinx like we were talking about in the fallopian tube, it's going to be removed the hydrosalpinx. The karyotype abnormality, we can do something called PGT-SR, which is IVF with genetic testing, but not the typical genetic testing that everyone gets, which is where you're just counting number of chromosomes. This is actually looking specifically to make sure that you don't have an embryo effect of the translocation. That's another step further in terms of genetic testing and that would be the treatment for that. Obviously, if there's any sort of thyroid abnormality, new diagnosis of diabetes, like getting your medical diagnoses under control and managed is going to be very important. I think the treatment gets harder when you don't have an answer. Because these are very specific. Like if you have a cause, we have an answer for you. If you don't have a cause, it's kind of like, ooh.

Abby Eblen MD (30:34)

Yeah, that's what I going ask. Yeah.

Susan Hudson MD (30:39)

Moving to that, if you have somebody who doesn't have a cause, what are some of the treatment options that are available? How do you guide patients in that circumstance?

Shelley Dolitsky MD (30:54)

Yeah, a lot of times it's a shared decision making and a conversation with the patient. And certainly if the patients are older, I said this early on, but when you're 40 years old, your chance of having a pregnancy loss can be as high as 75%. So the likelihood of you having more than one pregnancy loss strictly because an abnormal number of chromosomes is actually very high. And for those patients, a lot of times the answer can be IVF, do genetic testing of the embryos, and know that you have a normal embryo that you're putting back. That can sometimes, even if there's no cause, that can be a great option for people.

Otherwise, when patients are younger, sometimes you're just trying to help them get pregnant, give them progesterone to hopefully sustain pregnancy, not that that's always so effective. And obviously that's very controversial. It depends on what the patient wants to do, especially when there's no cause. I find a lot of patients want to do IVF with genetic testing as if they have no cause.

Susan Hudson MD (31:49)

This is a lot of where your heart and your mind come together. The individual or couple are the only people who know how much emotional capital they have. And I think we've all had what I would consider the exception to the rule of somebody who's like, I'm just not gonna do anything. We'll let you know when we get pregnant and then we'll just do supportive care.

The data behind those types of situations is actually good that most of those people are going to be successful. But the hard part of that conversation is we don't know if that next successful pregnancy is going to be the next pregnancy or four pregnancies down the road. We've all had that patient who went on and had multiple more miscarriages and eventually were successful. But I would venture to say most people don't have the time or enough emotional capital to go through that over and over and over. And I think that's normal. A lot of times people go on to look at things like IVF, because at least we know we're putting back a chromosomally normal embryo and eliminating that major factor.

Shelley Dolitsky MD (32:57)

I think one of the other big things that I've come to see with patients is that they have to, first of all, if they have insurance coverage, it's a big part of it, that this is gonna cost them a lot of money. And if they don't have insurance coverage, then it is, it's how much, what is their emotional bandwidth? How much can they take instead of paying out of pocket for IVF?

That's a very personal decision that I try to counsel as much as possible and then they decide.

Abby Eblen MD (33:33)

Hey, Shelley, for the couple that continues to and get pregnant, ⁓ what percentage chance would you give them if they're going to have a healthy pregnancy at one point? And does it matter if they've had a baby before or not?

Shelley Dolitsky MD (33:37)

So it certainly is a positive prognostic factor if they've had a baby. I give the same numbers that I had said before. If you have two pregnancy losses, your chance of your next pregnancy being the loss is 25 % and three pregnancy losses, it's 27%. So the truth is that more likely than not, you will be successful.

Abby Eblen MD (34:02)

So the flip side is 75 % chance of a good outcome potentially.

Shelley Dolitsky MD (34:05)

Right.

More likely than not, you're going to be successful. And I tell my patients also one of the benefits of coming to a fertility doctor, even if you're getting pregnant spontaneously on your own, we have the capacity to hold your hands a little bit more. We can get betas every 48 hours until you feel comfortable. You can come in for ultrasounds more often. I know that my patients who are looking to go to general OBs, at least in our area, they are swamped and very often can't get people in before they're 10 to 12 weeks pregnant. And if I, and we usually graduate OBs at eight weeks, but if they're not going to see their OB until 12 weeks and they want another ultrasound, come on back, come get another ultrasound. And if people want it every week instead of every other week, no problem. And that's something that we're so fortunate that we have the capacity in our practice to be able to do that. I think it helps a lot.

And actually there are studies that show that that actually leads to better outcomes. It's like TLC. Yeah.

Carrie Bedient MD (35:04)

Absolutely. Anything else that we need to throw into the consideration bucket for patients with RPL?

Shelley Dolitsky MD (35:13)

I think one of the things that we didn't talk about, and I'm sure this is just because we're getting very much into the medical stuff, but I think support groups and therapy and just realizing that after you've had even one miscarriage, that your next pregnancy is going to be stressful, that you are going to be more worried, that you're gonna be...very anxious about things going well. Even if everything is perfect, you're still gonna feel more anxious and that it's good to get ahead of it to help manage your stress, to be able to navigate that. I also tell people, two people will always deal with the same situation differently. One person is like ready to try again right away. And the other person is like, I cannot do that again. That was horrible.

Abby Eblen MD (36:00)

That's a great point.

Shelley Dolitsky MD (36:00)

And just realizing that navigating this is not easy and that's okay. And so you have to take it as it comes, but I think having good support group, having people to talk to, being open about things, if that's the type of person that you are, not keeping everything kind of inside. I say REIs or doctors, scientists, therapists, we're everything. I go through a box of tissues a week in my office because everyone who's coming in has some emotional story before they even walked in the door. And that's really something that I think I bring up at honestly all my visits, but certainly recurrent pregnancy loss visits.

Carrie Bedient MD (36:34)

One of the things that I will frequently have patients to do, especially in this situation, is I'll tell them repeat after me. This is not my fault. And I would say 70 plus percent of, probably closer to 80 or higher, they either can't get the words out or they absolutely dissolve and fall apart because...even if they know, even if they have been told this is not your fault, they take it as their fault. It's very internalized. I can't do this. This is my one job as a woman and I can't do it. And it's got nothing to do with you. You didn't do anything wrong. But it is a very, very hard thing for women especially to accept that this isn't my fault. It's just, it's happening, but I didn't do anything to earn it, deserve it or cause it.

Shelley Dolitsky MD (37:19)

Yeah, I think that's really amazing.

Carrie Bedient MD (37:21)

Well, thank you so much for joining us, Shelley. This is such an important topic and it takes such a huge emotional toll on patients that I hope this is able to help some people and give them a little bit more context for what they're going through. And so thank you so much for joining us. We appreciate you. We appreciate you and your expertise.

Shelley Dolitsky MD (37:26)

Yeah.

Well, thank you so much for having me. This was very fun.

Carrie Bedient MD (37:45)

For our listeners, we have been talking with Shelley Dolitsky, who is an REI at Shady Grove in Maryland. And to our listeners, thank you so much for tuning in. We are grateful for you as always. Thanks for listening. Subscribe to Apple Podcasts to have next Tuesday's episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us to spread reliable information and help as many people as possible.

Abby Eblen MD (38:09)

Visit us on fertilitydocsuncensored.com to submit specific questions and make sure you sign up for our email list. Check out our new book, the IVF Blueprint, and you can get it at all major book sellers, including Amazon, Barnes & Noble, and bookshop.org.

Susan Hudson MD (38:25)

Check out our Instagram and TikTok for quick hits of fertility tips between weekly episodes. And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye.