Ep 322: Answering your Questions about Pregnancy Loss

 Fertility Docs Uncensored Today’s episode of 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 question-driven episode, we take a deep and thoughtful look at pregnancy loss, especially for patients who feel stuck after “normal” test results. We explore what additional evaluation options exist when standard workups don’t provide answers and discuss how thinking outside the box can uncover overlooked causes. What testing can be considered after recurrent pregnancy loss with normal results? We discuss sperm DNA fragmentation testing, uterine evaluation with saline sonogram, and when to consider less obvious causes such as tubal factor, particularly in cases of recurrent pregnancy loss of unknown location or repeated very early losses. Could some early losses represent undiagnosed tubal pregnancies? We walk through that possibility and when it should be investigated. How does endometriosis impact implantation and miscarriage risk? We review the role of the Receptiva assay and BCL6 as a marker of inflammation that may contribute to failed implantation or early pregnancy loss, particularly in IVF cycles. We also explain how IVF can shift the “tipping point” by helping identify embryos with chromosomal abnormalities, which are common due to egg-related factors and increase with age. Why does time matter more as women get older? Each miscarriage can take months to resolve, delaying future attempts and compounding age-related fertility decline. Finally, we address the emotional toll of recurrent pregnancy loss and the importance of building resilience through counseling, journaling, and support systems. 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 (01:17)

Hello and welcome to another episode of Fertility Docs Uncensored. I am one of your hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas. I forgot for a minute where I was from. I am joined by my two terrifically talented, talkative, tenacious, and tenderly thoughtful co-hosts, Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center.

Abby Eblen MD (01:28)

Hey everybody.

Carrie Bedient MD (01:43)

How are you guys doing?

Abby Eblen MD (01:44)

We're doing fabulous.

Susan Hudson MD (01:46)

Doing good.

Carrie Bedient MD (01:47)

Okay, I have a deeply, deeply important question to ask both of you before we start our question episode on pregnancy loss. But my question for you today is if you were gonna open your own food truck, what would it be?

Susan Hudson MD (02:03)

You wanna go first Abby?

Abby Eblen MD (02:05)

Yeah, mine would actually really, I don't think this would count as food, it's really hard to make candies. And so I can do divinity pretty well. I'm still trying to get peanut butter fudge down pat, but I would like some sort of food truck that's really a dessert truck, a truck of dessert. That's what I would want to have. I want to learn how to make toffee and just all kinds of candy like things.

Carrie Bedient MD (02:26)

Okay, what about you Susan?

Susan Hudson MD (02:28)

Food truck for gluten free comfort food.

Abby Eblen MD (02:31)

Perfect.

Carrie Bedient MD (02:32)

Yeah.

Susan Hudson MD (02:32)

So all the things you really want to have like cinnamon rolls or macaroni and cheese or whatever kind of that type of comfort food type of stuff, but gluten free and true gluten free so that celiacs like me could go there and not be worried about cross contamination and things like that. That that would be my food truck.

Carrie Bedient MD (02:59)

That sounds fabulous.

Abby Eblen MD (03:01)

I would like my dessert truck to have no calories in the desserts. That would be the other thing.

Carrie Bedient MD (03:06)

I am now just imagining all of the sugar-free cellulose type base.

Abby Eblen MD (03:11)

No, no, it tastes just like it has sugar in it, but it would be sugar-free. That'd be the twist.

Carrie Bedient MD (03:16)

Hmm.

I feel like that's from the same type of culinary physics where if you eat a cookie standing up, there's no calories to it. Or if you break the cookie in half, all the calories fall out.

Yeah, no, I have all of those culinary laws down pat.

Susan Hudson MD (03:34)

What would you do, Carrie?

Carrie Bedient MD (03:36)

I think I would open up a brownie food truck and it would have all sorts of brownie sundaes where you've got kind of the warm gooey base with all the different types of ice creams and sauces and things like that in it. Or you could have just the plain brownies with all of the, the marshmallows, the fudge, the peanut butters, the toffees, the all of those different flavors built into it. I think that's what I would do.

Abby Eblen MD (04:03)

Girl after my heart.

Susan Hudson MD (04:04)

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Carrie Bedient MD (05:22)

So today we are going to do a question episode and we are going to do all of the questions that we have gotten. Well, maybe not all of them because that is an inordinate number, but some of the questions we have gotten about pregnancy loss. So Susan, what you got?

Susan Hudson MD (05:40)

Okay, our first one is, I am 36 years old and my husband is 42. The last three years we had recurrent miscarriages four in which the embryo typically dies around week seven to eight. One was earlier with no embryo seen, only a crumpled sack. We have gone through RPL testing with tons of blood work, karyotyping, hysteroscopy, sonohystogram, and semen analysis, including DNA fragmentation. The only finding was an arcuate uterus.

We conceive quickly within one to three months each time. Unfortunately, we have not been able to test the embryos for chromosome issues. Question one, why is this happening? Two, will IVF with PGT-A help us if the cause of miscarriage is unexplained? Three, do you have any suggestions?

Abby Eblen MD (06:28)

I think early on when we first started doing genetic testing, one of the things that really showed that it had the most promise, or one of the groups of patients that had the most promise with PGT-A was women with recurrent pregnancy loss. We thought it was gonna be women over 40, but really that, the of recurrent pregnancy loss patients tended to benefit mostly from it early on. And probably a lot of that has to do with the fact that about half the time when a woman loses a pregnancy, it's due to a genetic abnormality.

In theory, if you've lost four pregnancies, two of those could have been genetically abnormal. And it's not that doing genetics can really overall change your chances per se, but it just, changes the tipping point a little bit. It gives you a better chance of having a genetically normal embryo. So I guess it does change your chances because it gives you a better chance of having an embryo that's gonna implant and do well.

Carrie Bedient MD (07:17)

It sounds like a lot of the testing that you've had is the stuff that you need to have had and with unexplained infertility. Granted, your age is 36 and that is a point in time where, for the most part, we don't attribute a lot of chromosomal abnormalities to age 36, but it can certainly happen. Everything is on a spectrum. When you think about the bell curve, most people are under the high point of it, but there's always going to be somebody who's out at one end or the other. And that can include having less organized chromosomes, even at age 36, which is otherwise younger than we usually attribute a ton of those problems to. So I think you've had the good testing to do. I do think that thinking about IVF with the PGT-A may be helpful if for no other reason it may save you some heartache. People don't give enough credit to just how hard miscarriages are and how much strength it takes to go on after one. If you can maybe save yourself a little bit of that heartache, so much the better.

Susan Hudson MD (08:18)

I think an important thing to understand is in people who have a recurrent pregnancy loss evaluation, 50 % of them don't have something that's identifiable. And I think most of us would agree that most of those people who fall into that unidentifiable recurrent pregnancy loss, that for some reason, chromosomally abnormal embryos tend to stick in some women longer than in others. And the data is very clear that most people with recurrent pregnancy loss are going to be successful. We just don't know is that the next pregnancy or three pregnancies down the road. And what doing IVF with PGT-A does is it helps us at least eliminate that factor. We know that the embryo going into your uterus is chromosomally normal. It's not perfect.

We still have people who have miscarriages, but I can say, especially in that recurrent pregnancy loss group, that it does seem to have a very positive impact, both physically as well as mentally and emotionally.

Carrie Bedient MD (09:22)

Excellent. What's our next question?

Susan Hudson MD (09:24)

Okay, our next question is, am 37 and had one healthy child with no medical intervention at 35. It took us over a year to conceive her and we were exploring IUI and IVF options when I got pregnant naturally. We decided to try again for number two and I got pregnant right away this time. Unfortunately, I had a missed miscarriage at around nine weeks and had a D&C. Testing on the baby boy revealed maternal triploidy. My OB did not recommend follow up genetic testing. Do you agree? I'm terrified to try again. We are not in a mental or financial space to try IVF.

Abby Eblen MD (10:02)

I think with the triploidy again, it goes back to just as women were born with all the eggs that we'll ever have and just the egg just doesn't divide sometimes the way it's supposed to. And so generally for things like that, we don't feel that there were recurrent things that would happen over and over again. Like Carrie says, it's like pulling the lever on the slot machine in Las Vegas. You just don't know what genetics you're going to come up with. I think in this situation, if you feel uncomfortable, certainly you could see a genetics counselor, but I don't know that they're really going to give you information other than just to tell you it just was kind of bad luck basically.

Carrie Bedient MD (10:34)

Yeah, triploidy is a complete duplication of one of the sets of chromosomes. so instead of having 46, you've got 69. And that's something that fortunately doesn't tend to be hereditary or repetitive in the same way that we see some of these other abnormalities that can be associated with chromosomal translocations or things that are a bit more permanent, a little bit harder to work around. It's really just related to the accidental separation or lack thereof and I know you're terrified of this happening again but this is one of those things where you had nothing to do with this. This just is. This is not something that you did, said, didn't do, can control and to a degree the only way to find out if it's going to happen again is to try again and the likelihood of it being triploidy again is actually pretty low.

Although there's absolutely likelihood of having some other abnormality going on. And that's part of the gambling of trying to have kids. You may have to take the leap of faith, particularly if you're not in a space to do IVF where you can control for it. You may have to decide, all right, are we ready to take that leap of faith and just give it a shot, not knowing what the outcome is gonna be.

Susan Hudson MD (11:48)

On the positive side, also know that in the first few months after a miscarriage, you have higher chances of having a successful pregnancy. I always encourage patients to take advantage of that little blip of natural increase because we see people all the time who are like, we had a miscarriage and we just couldn't keep on moving. Then it's six, nine, 12 months down the road. And besides the fact that a whole nother year of ovarian aging has happened, you've missed that little natural increased blip of success rate that you might have been able to take advantage of.

Abby Eblen MD (12:26)

And one other thing I'd just like to say too, and Carrie said something that made me think of this and Susan too it's really important to really try and be resilient. It's so hard to do that when you keep getting negative results and negative results. And I think recurrent pregnancy loss is almost worse than not being pregnant at all because you get your hopes up, you get excited, and then they get dashed. And it goes over and over and I think for some people, like Susan said, you just, after a while, you just can't keep going. And you're like, I just got to take a break and get away from this.

And sometimes that small break becomes a really long break. Whatever you can do to help, if it's counseling, if it's journaling, if it's hanging out with your best friend more often than you normally would, I think you just have to really try and reach deep inside and find a way to keep going. And for some people that is counseling, and I think sometimes that's the best way to really get through all this, because it's hard, it really is.

Carrie Bedient MD (13:19)

I have an idea for a place for patients who are undergoing fertility treatment with pregnancy loss or any of the nonsense that our patients have to go through. I think that we should create a Wreck-it room that is specifically for fertility patients. And I think we do things like put old ultrasound machines in there and we put like aisle displays of Pampers and pregnancy tests that they can just like baseball bat their way through. And I think that this is a viable idea to help our patients get through and that we totally need to create this specialty Wreck-it room for our patients to utterly destroy everything.

Susan Hudson MD (14:03)

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Carrie Bedient MD (14:41)

Okay, what's next?

Susan Hudson MD (14:43)

Our next one, Hi Docs, thank you for the podcast. It supported me through three miscarriages in 2025, all seven to eight weeks. I'm 33, husband is 36, based in New Zealand. We have a three-year-old daughter conceived naturally in 2022. I have endo plus adeno, last surgery was in 2019, long cycles, ovulating cycle day 21 to 24 with pain.

Husband's sperm includes SCSA, excellent. My AMH is 33, all blood's normal, thyroids, antiphospholipids, et cetera. I had a hystereoscopy showing a small benign polyp and mild endometritis, both treated. IVF in December, 28 eggs, 27 fertilized, 14 embryos, 4 sent for PGT-A, pending. Genetics from last miscarriage were normal.

Currently on downregulation, Zoladex and Letrazole 5 mg. Questions. What do my chances of success look like going forward? Will downregulation help implantation miscarriage risk?

Abby Eblen MD (15:51)

So she's got four blastocysts, but we don't know what the genetics are.

Susan Hudson MD (15:53)

PGT-A is pending.

So if we have PGT-A normal embryos, I think is her question. What are our general chances of success and will down regulation help?

Carrie Bedient MD (16:01)

Mm-hmm.

So general chances of success are going to be related to the IVF lab that you're working with. But in general, I would say with a PGT-tested embryo that looks good, you're in the 60, 70-plus percent range, especially because you're young and that's huge. And you've had the uterine testing, so that's a good sign. You've had a live birth before, that's a good sign. I think you've got pretty decent chances going forwards. I would consider, the one thing you haven't mentioned is weight and insulin sensitivity because you're very much describing with that AMH of 33, that is very much describing a PCOS type picture.

Susan Hudson MD (16:47)

She's in New Zealand and maybe that's due to the different, the different measures, different units. Yeah. I don't know, but it's a possibility.

Carrie Bedient MD (16:52)

⁓ the picograms versus nanograms. Or picomoles versus nanograms. Alright. Okay. That's fair.

That is a possibility. Well, she's got long cycles too. Yeah. I would think about some of the factors that go along with PCOS in terms of weight and insulin sensitivity and those types of things to consider if there's anything you can optimize there.

Susan Hudson MD (17:02)

She does have long cycles.

Abby Eblen MD (17:16)

The other thing I would say too is she mentioned endometriosis and adenomyosis and that her last surgery was in 2019. I don't know how easily available doing a Receptiva assay would be, but in this country, if I see a patient that's had endometriosis, sometimes I'll at least think about doing that biopsy. It looks for an inflammatory marker, BCL6. If you have that inflammatory marker, in some patients it can decrease your chances of success.

If I know that a patient has endometriosis, I usually offer that to them, or sometimes people will go back and do a second surgery. It depends on whether or not you're having a lot of pain, and I think you did mention maybe you were having some pain as well.

Susan Hudson MD (17:55)

But she is using Zoladex and Letrazole for down regulation. So I think she's essentially pre-treating and assuming this positive, which is a completely reasonable way of doing it and just bypassing the test. So I think that can improve your chances and I think it's strong work.

Abby Eblen MD (18:02)

I see. Okay. Yeah. Yeah. Yeah. Yeah. Yeah.

Carrie Bedient MD (18:03)

Yeah, yeah, I think you've got a pretty good shot at it. Keep us posted. We're curious. Let us know. Let us know. Fingers crossed. Hope it works for you.

Susan Hudson MD (18:23)

Okay, our next one. Hi, thank you so much for all of your info. Thank you for listening.

I am 37 and have had one round of IVF due to severe male factor infertility that resulted in three euploid embryos of high quality. We have one seven-year-old already that was conceived naturally without any issues. We have transferred two of the three embryos separately with a medicated FET and daily PIO, baby aspirin and prednisone on the second and have had two miscarriages between five to six weeks each time with beta levels that were perfect and normal ultrasounds at five weeks. All of my initial infertility tests came back normal and all of our RPL testing, blood clotting, autoimmune, karyotyping has also come back normal for both of us. Do you have any advice? We are devastated and not sure how to move forward.

Abby Eblen MD (19:13)

Any genetic testing done?

Carrie Bedient MD (19:15)

I think they're euploid embryos, aren't they?

Susan Hudson MD (19:17)

Yes, they're all euploid embryos and they've had normal karyotypes.

Carrie Bedient MD (19:21)

Would be interested in a hysteroscopy to take a look at the inside, see if there's any scar tissue, any inflammation, anything squirrely going on there. Check for adeno in the ultrasound.

Susan Hudson MD (19:31)

I think the Receptiva test for her would be very reasonable. Also, little concerned that we've had severe male factor and I'm assuming we had ejaculated sperm. So if we had DNA fragmentation, we know that that is related to recurrent pregnancy loss. And so if there's evidence of DNA fragmentation, this may be a situation where if you had to do another IVF cycle, may consider getting biopsied sperm instead of ejaculated sperm because the further upstream, the less likely it has had some damage.

Carrie Bedient MD (20:07)

That could be it.

Abby Eblen MD (20:08)

She didn't mention her endometrial thickness too. I just wonder what that is. Obviously, the thicker the endometrium, tend to, at least to certain degree, we think is better. But obviously, your doctor's probably working on that with medicines.

Mm-hmm. And considering if there's any lifestyle factors, I generally for IVF patients, all of that has been dealt with, smoking, drinking, drug use, including marijuana, cross-checking your medications, making sure that there's nothing problematic in there. For the most part, all that stuff tends to be dealt with long before people ever get to us. But just in case, if there's anything medically overall that you've been putting off that you haven't been evaluating that maybe you should think about,

Susan and her celiac disease can attest to that. All the autoimmune. Yep.

Susan Hudson MD (20:52)

And I know Carrie mentioned smoking, but when she says smoking also everybody always remember we mean nicotine intake of any types. So whether you're vaping, chewing gum, using patches, nicotine is nicotine and they're all bad for reproduction.

Carrie Bedient MD (21:07)

Agree.

Susan Hudson MD (21:09)

Okay, our next one. Thank you so much for your podcast. In a world with some much conflicting information, having access to your podcast has been a game changer for me. Thank you so much. That's exactly why we created it. I'm 37 next month. I had two healthy pregnancies, one in the end of 2017 and another in 2019, but then had a miscarriage and D&C in 2022, then tried for about a year and finally had to had another miscarriage in D&C in April of this year. My hormones are great. My period is regular. My doctor did a hysteroscopy in April and said my uterus looks great. What would you suggest my next steps be? I really want to avoid IVF, but I would love another baby. Do you think there's a chance I get pregnant on my own? I'm nervous. I will be told IVF is my only option.

Abby Eblen MD (22:00)

So there was, it looks like four years between her one loss and her second loss, is that right? From 2022 to 2026.

Susan Hudson MD (22:09)

2025, so three years.

Abby Eblen MD (22:14)

Yeah, I I worry a little bit about that your age may be having an impact. You're 37 now and I know you were younger back in 2022, but the thing that's different now is just your age. And as you get older, it's going to be harder. It's not going to be easier. I know you don't want to do IVF, but I think if you really want to have a third baby, I would strongly consider that because it sounds like pretty much everything else that's logical, that should have been done, has been done.

Just luck of the draw, you don't know what month it is that you're gonna get pregnant or if you're gonna get pregnant, but IVF can certainly speed that up a little bit. And so I think at this point, you've got to decide how important getting, having a third baby really is to you. And if it's real important, I would probably lean toward IVF at this point.

Carrie Bedient MD (22:55)

I think considering what your emotional resiliency tank has got in it right now is helpful because you can make an argument that for someone with your situation, you could try some cycles of clomid or letrazole insemination, things that might help speed up getting pregnant, but that's not going to do anything to change the risk of miscarriage. That's why I say take stock of where you are right now, because if you're at a point where if you have one more miscarriage, you're just going to totally lose it, then don't do that, please. But if you're at a point where you're like, I really don't want to do IVF, I can muscle through one or two or however many more miscarriages. If it means that I don't have to do that, then that may make sense to do a couple of cycles of oral ovulation induction agents with insemination to see if you can get pregnant and then, fingers crossed that it'll stick.

Susan Hudson MD (23:49)

Absolutely. Agree, agree.

Abby Eblen MD (23:51)

One other thing though I'd throw out there is each time you have a miscarriage that takes you out of the loop for probably a couple of months maybe three months max and so you had one and then you had another one I mean that's pretty quickly age is going to even become a bigger impact as you if you have more miscarriages.

Susan Hudson MD (24:10)

I am a 29 year old with no significant medical history besides being overweight. I have been the same weight since high school. I started trying to conceive our fourth child about 16 months ago. In this time, I had 10 early miscarriages before five weeks and one ectopic pregnancy that was treated with methotrexate. After about the sixth loss, I saw my OB. She had thyroid blood work done that was normal.

AMH is 2.6 and a transvaginal ultrasound that was very normal. I conceived my other children the first cycle of trying with each one. So I feel very shocked that I'm having so much difficulty. My OB tells me to keep trying, but this roller coaster of emotions is so much. What would cause such a dramatic change in my fertility?

Carrie Bedient MD (24:57)

She doesn't.

She doesn't mention anything about her partner. I wonder if a partner's changed.

Susan Hudson MD (25:04)

That would be my first concern. I'm thinking maybe making sure your partner, that we have chromosomes on your partner, make sure we have a semen analysis, make sure we have DNA fragmentation on his sperm. Those are all very possible things that could change the ballgame.

Abby Eblen MD (25:21)

When a lot of people have a lot of really early miscarriages, I worry about tubes too. So I don't know why.

Carrie Bedient MD (25:26)

Yeah.

Susan Hudson MD (25:27)

She has had an ectopic.

Abby Eblen MD (25:31)

So I would worry that something's going on with your tubes. I don't know if you've had, C-sections generally cause scar tissue. Endometriosis could, so even if you had vaginal deliveries, but now you have endometriosis, you could have scar tissue in your tubes. The sperm can swim through really tiny spaces and get to the end of the fallopian tube where it meets the egg, but the egg is much larger, it's the largest cell in your body. So as it tries to get back through the fallopian tube, it can get stuck. I worry that because you've already had one ectopic slash pregnancy of unknown location and all these, it's really unusual to have a whole bunch of really early losses like that after you've had three normal children.

Susan Hudson MD (26:08)

And I would say that making sure we're really truly talking about miscarriages, all of these being miscarriages versus and having one ectopic pregnancy or have we had pregnancies of unknown location that have spontaneously resolved because a pregnancy of unknown location that spontaneously resolves may have been in the uterus, but it may have been in the fallopian tube. So I do think that having an HSG performed, could have patent or open hydrosalpinx swollen fallopian tubes, which could be increasing your odds of having an ectopic pregnancy and increasing your risk of miscarriage because the fluid within the fallopian tubes when they're swollen is embryo toxic. It can actually stop a developing pregnancy and it can be flowing back inside the uterus and causing more harm than good.

Carrie Bedient MD (26:58)

Yeah, that was an interesting one because that hits from areas that we don't often think about because a lot of women, I think when they have multiple live births and they've got children, they say they're having miscarriage and the response is, well, you should be lucky. You've got you should feel lucky. You've already got children. And that doesn't doesn't make them feel better. I mean, it does in the sense of, yes, they've got a lot of action in their lives and they have a lot to be grateful for. But that doesn't take away the pain of our family's not complete yet. And so I hope that you are able to have another small human join your family and that it all all works out well.

All right, well, so that was a lovely episode of going through all of those questions that we hear all the time. For anybody who's going through this, you are not alone. You are in very good company with a large amount of people. Thank you so much for listening. Please listen and subscribe on 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 (28:05)

You can also visit us on fertilitydocsuncensored.com to ask a question for our Ask the Docs segment. Also check out our new book, the IVF Blueprint, to help you better understand IVF in detail. You can find it on Amazon, Barnes & Noble, and bookshop.org. Or we'd love for you to subscribe and leave us a review on Apple Podcasts. We'd really love to hear from you.

Susan Hudson MD (28:26)

Check out our Instagram and TikTok for quick hits of Fertility Toast between weekly episodes. And as always, our podcast is intended for entertainment

is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye.

Carrie Bedient MD (28:42)

Bye!