In this episode of Fertility Docs Uncensored, Dr. Susan Hudson of Texas Fertility Center and Dr. Carrie Bedient of Fertility Center of Las Vegas answer listener questions about miscarriage and pregnancy loss, including IVF medication, subchorionic hematomas, recurrent loss testing, and what to consider before another transfer. They share evidence-informed perspectives and acknowledge the emotional weight of loss, while reminding listeners that care should be personalized with their own physician. Listen in for expert advice and opinions on questions about one of the most traumatic diagnoses women experience in their reproductive years, and how a “normal” embryo can still result in pregnancy loss.

Episode 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.

Susan Hudson MD (00:22)

This episode is brought to you by Receptiva DX. What if unexplained infertility isn’t actually unexplained? For many women, hidden inflammation associated with endometriosis and other uterine conditions can go undetected for years, even when everything else appears normal. For more than a decade, fertility specialists have trusted Receptiva DX to provide deeper insight into the uterine environment. Helping women and their physicians uncover answers and make more informed treatment decisions.

Carrie Bedient MD (00:52)

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. And I am joined by my sexy sassy stupendous co-host, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (01:06)

How are you doing, Carrie?

Carrie Bedient MD (01:08)

Good, how are you?

Susan Hudson MD (01:09)

I am good. I am seeing that you have a new lipstick on today.

Carrie Bedient MD (01:12)

I do, and I’m so pleased with myself. And I need to thank you because so for any of our listeners who’ve been around for any number of episodes, you kinda know that I am not particularly good at being a girly girl, especially when it comes to doing hair and makeup. When Susan and I get together at conferences, she has bailed me out more than once in terms of going to events and her doing my hair and and those types of things. I heavily rely on her steamer.

So that I don’t look like a wrinkled mess. By the way, I did actually buy myself a travel steamer so that I no longer look like a traveling mess by myself. but the last time that we were together, she showed me a new lipstick, which is one of those stain things that you put on. It’s bright, bright purple, which my husband looked at me the first time I put it on and went, What the hell?

Because bright purple and going goth is not my typical MO. But it’s fabulous because you put it on and it lasts all day. I put this on, I don’t know, seven, eight hours ago and it’s still on and it’s great.

Susan Hudson MD (02:14)

It is. I love it. So little shout out to Wonderskin. And I know you look funny. I have to say that if I ever did go goth, like the bluish, purplish, iridescent thing actually does work pretty well. And I bet it actually looks pretty good on you, us being really fair skinned.

Carrie Bedient MD (02:30)

I’ve actually debated do I not take it off? Do I leave this on?

Susan Hudson MD (02:33)

Yeah, my family one time I was walking around letting it dry and they’re like, What in the world are you doing?

It was great. It was great. But it does last and I mean it’ll easily last, eight, nine hours and at most you’d put on twice a day if you’re going out in the evening. So it’s good stuff.

Carrie Bedient MD (02:51)

So Wonderskin people, if any of you are listening, we’re fans. So, if you want to sponsor the podcast, we will happily rep for you guys.

Susan Hudson MD (02:58)

Absolutely.

Carrie Bedient MD (02:59)

Okay, so today we are going to do a question episode. And it has been a while since we have tackled this topic in terms of listener questions. And we are gonna go through all of the, not all of the questions, because that would take us 12 hours of recording time.

But we’re gonna go through several of the questions about pregnancy loss and miscarriage. Trying to figure out if there’s any way that we can help y’all consider this a trigger warning if this is not the episode you wanna listen to. But also it’s an would it be an anti trigger warning for the people it might help? I Anyway, do you wanna start with our first question, Susan?

Susan Hudson MD (03:33)

I will. And there is power in knowledge. So remember that when you’re listening. Okay, our first question is: how common is miscarriage after stopping PIO and estrogen? I just miscarried my euploid embryo at 11 weeks. This was my first FET and was fully medicated. Stopped PIO and estrogen at 10 weeks. They also said I had a small subchorionic hematoma when I miscarried. I am 29 with stage two endo, and this was my only pregnancy.

Would love any insight as I have only one more embryo left. Appreciate all that you guys do. Well, thank you so much for listening. I think there’s a lot of important things in this one. Carrie, start off with when does the placenta really take over the production of estrogen and progesterone?

Carrie Bedient MD (04:21)

Placenta usually takes over production of estrogen and progesterone somewhere in the six to eight week mark. So I would say most of us continue meds on through at least eight weeks. And oftentimes we will continue beyond that because we are control freaks and people may want to throw their meds plus or minus the needles at the wall after being on PIO for a while, but it does very little harm.

For the benefit that it may provide. And so most of us go well beyond the point that we need to with the placenta taking over production. And by that point, I would anticipate that the the placenta is fully taking over. How does your clinic do it, Susan, with with tapering off meds. Do you go cold turkey? Do you check levels? How do you guys do it?

Susan Hudson MD (05:06)

This is one of those great examples of the art of medicine. So even within our practice, we don’t all do the same thing. I generally continue progesterone, estrogen until someone is 10 weeks. And then I usually stop meds. And if I have somebody who’s super anxious and they want to wean down, I’m like, fine, the only thing that’s hurting is your backside and it’s it’s not gonna hurt anything, but at that point I truly feel you’ve had well over a week that the placenta should have fully taken over and that type of thing. There are a number of people in our practice who follow hormone levels and will gradually taper down. Some people just follow hormone levels and stop. It is as many ways that you can skin this cat is the way you can do it.

Carrie Bedient MD (05:55)

We tend to taper and then follow hormone levels down. But I would have to say there is maybe one person a year that I actually have to restart something on. And it it tends to be really a pretty rare occurrence. Out of out of all the patients that we see, it is very unusual to have to restart meds by the time we have started tapering someone. And we’ll taper somewhere between week nine and 10, depending on when they’re coming in for that last ultrasound.

So how common are miscarriages?

Susan Hudson MD (06:25)

Miscarriages are very, very common. Even with chromosomally normal embryos, we probably still see somewhere around a five or ten percent risk of miscarriage, depending on the age group and the situation. And realize that when people are naturally trying to get pregnant, risk of miscarriage is usually if you’re less than 35, is going to be around 15%. However, by the time you get to forty, that risk of miscarriage can easily be in the forty plus percent range.

Carrie Bedient MD (07:01)

And how are those miscarriages spread out over time? When in a pregnancy do they tend to occur? What’s the riskiest point? When are you better able to breathe?

Susan Hudson MD (07:11)

So the biggest time that you are most likely to have a miscarriage, I would say is before six weeks. Most miscarriages are going to happen in the first trimester for sure. The most are going to be biochemical pregnancies where pregnancy hormone levels go up and then they drop. And the further along you go, the less likely a miscarriage is to happen. There’s a statistic out there that of pregnancies that you can see a heartbeat, only 5% of the ones after that are going to miscarry. So, in the grand scheme of things, once development has happened to that point, most people are going to be fine. Now, when you look at people who are in an infertility clinic, that percentage is going to be higher, but we’re not looking at all of the population. We’re looking at a very small percentage.

Carrie Bedient MD (08:02)

Absolutely. And then the next component of this is she mentioned she had a small subchorionic hematoma that was noted when she miscarried. So what do you think about that? What do you think about subchorionics? How do you counsel your patients when you’re doing that pregnancy ultrasound and you see one?

Susan Hudson MD (08:19)

The way I generally describe the subchorionic hematoma is essentially as the pregnancy is getting bigger and bigger, sometimes a little blood vessel can get nicked or something’s not going exactly the way we expect, and you end up having some bleeding. It’s just how it appears on ultrasound. So though a subchorionic hematoma or hemorrhage is concerning because all bleeding in pregnancy is concerning. First of all, they’re very, very common, especially in IVF pregnancies. And I mean, I can say I had one myself. My daughter is almost 16. I remember that day like it was yesterday. It can be scary as hell. But on the positive side, most people with subchorionic hematomas are going to have normal deliveries of healthy babies. Just because you have subchorionic hematoma doesn’t necessarily mean that you’re going to miscarry. And if you’re already miscarrying, it’s just a sign that things are separating and dividing out of the uterus to ideally help you pass that miscarriage so that it can resolve and then we can move to the next step. Carrie, what are your thoughts on the positioning and size of subchorionic hemorrhages?

Carrie Bedient MD (09:35)

As always, size matters. And most of the time, even actually with a bigger subchorionic, part of what makes subchorionics scary, especially when you see them very early in pregnancy, is that the relative size of the hemorrhage compared to the pregnancy looks awful. It looks so frightening because it looks like you’ve got a hemorrhage that’s bigger than the entire gestational sac. And that may potentially be true.

But especially as the baby grows, usually the subchorionic isn’t growing at a commensurate rate. As you get further into pregnancy, the subchorionic gets smaller and smaller. If you have an exceptionally large subchorionic that takes up, probably 50% or greater of the uterus, okay, let’s start worrying. Most of the time they’re much smaller than that.

One thing that makes subcorionics particularly crazy making for patients is that if they’re located right over the cervix, that blood is going to take the path of least resistance. And if it’s right over the cervix, oftentimes that path is down and out such that you are seeing bleeding. Sometimes it’s red, sometimes it’s brown. either way, it is absolutely crazy making.

That is one of the scariest things, I think, for patients, because you see this blood and this pregnancy you have worked so damn hard for. And then you go in and you’re diagnosed with a subchorionic hemorrhage, and your brain just cascades into a doom spiral. And a lot of the times that’s not reality. And it’s fabulous. Now we can tell you until we’re blue in the face that it’s not reality and that most likely everything’s gonna be fine, but We don’t know, we can’t see the future. And when you’ve worked this hard to get a pregnancy, it just it puts people on edge. That part is very, very common.

Susan Hudson MD (11:13)

Things to know that brown spotting after you’ve had a subchorionic hemorrhage can go on forever, like weeks, and it’s just a pain in the patootie and it’s annoying and it’s a reminder, but generally brown stuff we’re not too concerned about because that means it’s old. The other thing to know is that blood is a uterine irritant, so it’s very, very common to have cramping with a subchorionic hemorrhage and realize it’s nature’s way of trying to help get rid of what’s irritating the uterus. The key is to have enough cramping to get rid of the blood, but not enough cramping to actually miscarry, which is what happens most of the time. Now if you do have a subchorionic hemorrhage, you are at a probably a little bit increased risk of things like preeclampsia, which kind of makes sense because preeclampsia is related to good healthy placentation or how well the placenta is developing and attached and that type of thing. But Carrie, what’s the last thing this listener talked about that kind of makes you say, hmm, maybe we might do some additional testing?

Carrie Bedient MD (12:20)

So she mentioned she’s got stage two endo. And endo and adeno are very closely related. I’m going back and forth about how important I think this is in her specific case, mostly because she made it out to 11 weeks. And in many cases, when we see endo, adeno…those diagnoses impact your ability to get pregnant or their very early miscarriages. They tend not to come in later. But one thing to consider is okay, is this worth doing Receptiva testing? Is this worth doing Lupron prior to your next transfer to help prepare the uterus? I think really the best news in all of this is that you were able to achieve a pregnancy and get that far into it. So that means that the protocol that they used is pretty solid and and you know that it works in your body because you got that far because by this point it has nothing to do with the protocol, most likely, that you miscarriage.

Susan Hudson MD (13:15)

Absolutely. And also know that there’s more to healthy developing babies than just chromosomes. That even though you did everything right, your doctors did everything right, there may have just been something that was developing within the baby that wasn’t developing normally. Maybe the heart wasn’t developing normally or the liver or the kidneys, something that’s vital for the baby to live and develop and survive.

I would say I think you still have very good chances of being successful in the future. I don’t think that you stopping your estrogen and progesterone was actually the cause of you having this miscarriage. And we wish you the very best in your next embryo transfer.

Carrie Bedient MD (14:00)

Absolutely. Alright, so our next question. Hi gals, my husband, 37, and I, 34, have been trying for 15 years. Ectopic with right tubal loss 10 years ago and started IVF last year. We transferred our 4AA PGT normal embryo about two months ago, and the betas rose perfectly. We found out one month later that the pregnancy stopped growing at five weeks one day. We’ll be taking medication to pass it.

All of our tests and levels were perfect. We had a subchorionic hemorrhage a week prior, but Doc still found gestational sac and yolk sac. I’m devastated. Is moving forward with the same protocol a good idea or should we ask about changing something? My doctor doesn’t have an exact answer for what happened, of course, who knows sometimes. But this is all feeling so much more out of control than it has been for the duration of our IVF journey. I’m literally helpless advice needed.

Honey, like all of our listeners, you are going through it. So again, and we all say this forever and ever amen. You didn’t do anything wrong. And neither did your doctor, because the pregnancy managed to implant. The betas were going up perfectly by the textbook. One of the things that we can look at with PGTA is the number of chromosomes.

And depending on the exact type of PGTA, if there’s any big areas of deletion or duplication where you’re missing big chunks. So the whole chromosome is there, but it may have a little too much or not enough material within it. What we don’t do and don’t really have great capacity for is knowing how each one of those genes is functioning. There’s an awful lot to the growth of an embryo besides just is the instruction manual present or not? Because you need the instruction manual present. You need every single page intact and you need it to be in a language that you know how to read. But there’s a lot that can go wrong. If you’re missing just a portion of a page, if there are a couple of keywords that are blacked out, that means that those instructions aren’t good. But it’s not something that you’re going to necessarily pick up, obviously.

The other component of it is that things don’t just happen with the instructions. You need machinery too. And so if all the machinery is not working exactly how it’s supposed to be, which we don’t have a good test for that, there’s really no way for us to get into those little organelles and find out if the smooth endoplasmic reticulum or the rough endoplasmic reticulum is functioning the way that it should, right next to the Golgi apparatus and all of these other terms from cellular biology from when I was a college freshman that I have not thought about in quite some time. There’s no way for us to test that. And as a result, it means you’re working with machinery that you can’t see and you can’t test. And sometimes springs go boing. And a spring can go boing in a way that stops a pregnancy at five weeks, one day, without anybody having a great explanation. Oftentimes that’s one of the things that’s going on. Typically in a clinic They’re watching your hormone levels really closely. You are watching what you’re doing really closely. IVF patients, thankfully, are not the ones that we’re worried about all of a sudden drinking a lot, smoking, using drugs, doing things that have a negative impact on overall health. But it’s something that can happen and it’s very hard to diagnose because there are so many other things that can go on. What do you think about this case, Susan?

Susan Hudson MD (17:19)

Kind of thinking about if this was my patient, what are some things I would do? I would want to make sure that you have actually had an HSG, a dye test of the fallopian tubes. I know you’re missing one tube, but you’ve had a ectopic pregnancy. And sometimes in clinics, people will be like, you know what, you’ve had a ectopic pregnancy, let’s go to IVF, we’re gonna bypass the tubes. That was a completely normal and reasonable thing to do.

But I would want to make sure that that other fallopian tube is not a swollen fallopian tube, a hydrosalpinx. Because the fluid within a hydrosalpinx can go back into the uterus and be embryotoxic. So that would be one thing I would want to make sure that you’ve had done. I would usually at this point with somebody who’s had a miscarriage after transferring a PGTA-tested embryo.

I would do antiphospholipid antibody testing. This is a blood test, which is a panel of usually between six to 10 different tests that looks for an acquired blood clotting condition. If you have this test and it ends up positive, we then repeat the test in 12 weeks because there’s so many things that could be a little blip. We want to make sure blips are actually true abnormal values.

And if it remains positive, then you might be a candidate for blood thinners like Lovenox or Heparin in addition to a baby aspirin during pregnancy. I’m stingy with blood thinners. I love them when they’re appropriate, but I don’t give them to just anybody just because something didn’t work. Blood thinners can turn something like a fall or a minor car accident into a really big deal. I think there’s some responsibility there.

Carrie Bedient MD (19:01)

What do you think about the same protocol? Is moving forward with the same protocol a good idea, not a good idea?

Susan Hudson MD (19:06)

Probably in the future use some sort of steroid based protocol for you. That’s what I do for people who have had a history of miscarriage. Is there a lot of data to support that? No. But I think that a lot of people would choose to do that. If you’re already doing that, then I don’t think there’s a lot to change with that.

I don’t think necessarily going from a programmed cycle to a modified natural cycle is really gonna have a lot of impact in miscarriage in in this type of situation. What are what are your thoughts, Carrie?

Carrie Bedient MD (19:39)

I think that once you get implantation, once you get growth and things start going forward, I think that protocol changes don’t make a huge amount of difference. Really the benefit of the protocol is get the lining thick so that it’s able to implant. Everything else is done either by the embryo or by the uterus. It’s not necessarily influenced by the hormones that are being given.

I don’t see a whole lot of need to change. We know that that protocol works for you and so would tend to use the basic tenets of that again. Now getting testing to see do you need blood thinners, do you need anything else, totally worthwhile because those things may be beneficial when added. But I don’t know that adding anything is going to make a huge difference in terms of changing your protocol.

Susan Hudson MD (20:25)

So what would you say, Carrie, about the emotional aspect of this?

Carrie Bedient MD (20:30)

You are not alone. You are very much not alone. And everyone handles pregnancy loss in a different way. Some people are very vocal, some people retreat into themselves. Spouses handle things differently. You can handle things very differently from day to day, week to week. And I think that if you have someone to talk to outside of your spouse, so definitely talk to your spouse. They’re in this with you. But there are so many people who’ve had miscarriages and it’s not talked about. And I bet if you were to work into an office setting and take a poll of all the women in the office, at least some of them have had miscarriages and they can help walk with you through it because you don’t really know until you’ve been through it exactly what it’s like. It is an absolute loss. It is the loss of a potential, it is the loss of a hope and a dream and something you’ve gotten attached to. Whether it’s finding someone, a support group, a therapist, any or all of those is both helpful and very valuable.

Susan Hudson MD (21:33)

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Susan Hudson MD (22:32)

All right. Our next one. Hi, thank you so much for the work you are doing. Thank you for listening. I really like your podcast and appreciate you providing your expert experience and opinions. It is so helpful. I had a question about exercise and recurrent pregnancy loss. I’m a highly athletic ultra marathon runner.

And I know there is a lot of stigma around exercise and fertility. However, I am highly educated and experienced in fueling appropriately and maintaining healthy body weight to support reproduction. I have had very regular 29-day cycle for the past decade. I’m 31 years old and over the past year I have become naturally pregnant twice and miscarried at seven weeks and then at eight weeks.

The only thing in the RPL workup was that I had a TSH of four. Would love your thoughts.

Carrie Bedient MD (23:18)

What do you think about ultramarathoners and pregnancy and how those two things intersect?

Susan Hudson MD (23:22)

Well, as somebody who is not a runner, all I can interpret ultra marathoners are like marathoners on steroids. Which I’m assuming that’s what a ultra marathoner is, the people who do marathon after marathon after marathon.

Carrie Bedient MD (23:36)

Well, it’s like doing instead of a twenty six point two mile marathon, it’s like fifty miles, a hundred miles, all in one race.

Oftentimes they are done in very inhospitable conditions. Like some of the more famous races are, in Leadville, which is up in the mountains of Colorado, or across Death Valley. Badlands. Like really these are very intense people oftentimes. Now, not every race is like that, but but an ultra marathon is usually fifty miles plus.

Susan Hudson MD (24:05)

Okay, with that piece of information, I definitely have an opinion. So I would explain it to you in this type of situation. You first of all, I understand that you’re having regular periods, but regular periods do not equal fertility. And I can explain it to you in a way not necessarily relating to having the regular period, but most women between the ages of 40 and 50 still have regular periods. That does not mean that there aren’t problems in conception. And when you think about your body in caveman days.

If you were a caveman and you were having to run fifty miles, this is not the type of stress that the average human body should endure on a regular basis. And if you were having to do this, it might not be a great time to grow another human. I mean there’s no studies looking at ultramarathoners and recurrent pregnancy loss and that type of thing. The number of people to involve in something like that it’s just not feasible to create that type of study. But I would say that my advice would be cutting back and really focusing on more moderate exercise while you’re trying to conceive and during that first trimester. And there’s lots of people who do lots of physical activity and stay very active and exercise, but I don’t think that this is probably the best activity for being conducive to pregnancy.

Carrie?

Carrie Bedient MD (25:48)

I think it’s worthwhile to take it much easier during your first trimester, especially. And I say this as someone where I ran a half marathon, which is nothing near an ultra, but I ran a half marathon when I was about 13 weeks pregnant. Straight up and then straight down a hill. I have no objection to exercise during pregnancy. I did it all the way through. but I think I think there is a layer of stress on your body that is worth paying attention to. I do think that making sure you’ve had the full RPL workup, not just the labs, but the hystoscopy, the genetic testing for both of you, those types of things is well worth doing. It sounds like you’ve already had that done. So good work for that.

I think that this is a worthy thing to say, all right, I’m gonna back off and I’m gonna try something different. And even if it’s just continuing on with your normal training until you get a positive pregnancy test, and then saying instead of running a hundred miles a week or two hundred miles a week, whatever your training regimen is, you back off very heavily and you cut it down to maybe a 5k a day and pull back and continue to make a concerted increase in the amount of nutrition you’re putting in. Typically, you don’t need to add a whole lot of nutrition just for the first trimester. It’s not that many calories you need to add. But for someone who’s likely got a very high metabolism based on what you’re doing, you may actually need to be one of those people who adds more than the average in order to help keep up with that. Now, exercise physiology is its own subworld. And I do not pretend to be an expert in that at all. And there’s not a doubt in my mind that you’re very good at knowing how to fuel and maintain. But I think you may need to think about that differently. especially making sure that you’re getting plenty of fats. Every hormone that we base pregnancy off of is based off of cholesterol. And you may or may not be eating a whole lot of fats. And that may be something that’s helpful to change in your diet, in addition to making sure you’ve got plenty of carbs and protein to build cells. The other thing is making sure that you’ve got appropriate hydration during it so you don’t have a lot of acid buildup. That’s not particularly helpful either. We know that women who have diabetic crises are more likely to have miscarriage. And even though your physiology is very different than that, there may be some elements that cross over. So even though the causative reason is totally different, the effect may be the same. I know it’s very hard to hear exercise less. And as a doctor, it’s very strange to say exercise less. But that may be the right thing for you in this in this case.

Susan Hudson MD (28:26)

I agree.

Carrie Bedient MD (28:27)

What do you think about the TSH of four?

Susan Hudson MD (28:29)

If I have somebody who has a TSH of four, I would go ahead and run thyroid antibodies to see if there is an autoimmune component to that little bit elevated TSH level. And if you have positive thyroid antibodies, I would then start you on low dose thyroid medication to help supplement. And there’s some reasonable evidence that say that that can improve your outcomes as well.

Carrie Bedient MD (28:53)

Next question. Hello, I am 31. My husband and I have struggled with infertility for two and a half years. My question is I had a miscarriage with my second transfer earlier this year. The doctors told me the meds to end the pregnancy was just gonna cause cramps. So did Google. However, I was in so much pain I ended up calling 911 later only to find out that they were contractions, not cramps. Why did no one tell me? Also, any advice dealing with moving forward and being pregnant after this and gearing up for my next transfer would be appreciated. I’m terrified. Thanks so much.

So let’s start with the simple part of this question, which is contractions and cramps. Those are the same thing. Contractions are with more of a purpose. Cramps don’t necessarily have a dedicated purpose. Whenever you contract a muscle, whether it’s because you are running, you are miscarrying, you are lifting something, you’re going to the bathroom.

All of those things are muscle contractions. And cramps are typically intense muscle contractions. They are the same thing. The name may imply something different, but when you look at what a contraction is, hearing muscle contraction, like what you would do to lift up a milk jug versus labor contractions, those have very different connotations, but they are ultimately the same thing. It’s the muscle moving to shift.

Susan Hudson MD (30:15)

I’ve never thought of it in this scenario, but contraction is what the muscle is doing, whether it’s when you’re having a period and it’s trying to squeeze out your endometrium because it’s time for you to shed it, or it’s when it’s contracting around a baby to push a baby out. Cramps are the feeling, the sensation that you have associated with that muscle action.

When people say I have menstrual cramps, they are having pain. The uterus is contracting, but I’ve never actually thought about the delineation of those words, but the this is very, very good information. Now that we’ve established cramps, contractions, how these words work together, things to understand when someone is having a miscarriage.

Everyone is for the most part is going to have some pain associated with passing a miscarriage. The further along you are, the more uncomfortable it tends to be. I also do see that if someone is able to pass a miscarriage on their own without having to add medications like Cytotec, which it sounds like this person had, it tends to, though it may be intense, it’s not as intense as if you are using cytotec. So cytotec is a pill and the pill originally actually has purposes for gastrointestinal belly issues. But a side effect of it is it does make the uterus cramp and contract. We often use it in this situation. There are other situations that we use it. If someone’s having a baby and after they’ve had a baby and they’re having lots of bleeding, sometimes we use this medication to help the uterus contract down to stop the bleeding. So there’s lots of purposes for this. But generally in this type of situation, what would happen is you would be prescribed a few of these pills. Again, it depends on what your doctor does, and you place them vaginally and they make you have pretty intense contractions, cramps to pass the pregnancy that’s inside the uterus. And it can be very intense. I can say in my practice generally, I have people take 600 milligrams of ibuprofen starting the time that they place that and have it scheduled every six hours. And on top of that, I usually give some Tylenol number three.

And I can say I am a narcotic hard ass. I do not give narcotics for hardly anything. This is one of the few times I do because it can be very intense. I’m sorry you didn’t have as much information knowing that it might be pretty darn uncomfortable.

I am so proud of you for sharing this so that other people can have the knowledge that sometimes when we’re doing this, it can be it can be quite a bit.

What are your thoughts, Carrie?

Carrie Bedient MD (33:16)

Advice moving forward. One thing that helps me because I’m a planner is knowing, heaven forbid if this happens again, what am I gonna do? You may be someone where opting for a D&C is a better option because they’re gonna knock you out and they’re gonna deal with it all at once. And the worst parts of it will occur while you are under anesthesia. So you may find that that is a much better option for you, and just knowing that you have that option going forward.

Helps you to feel better about it because you know you don’t have to go through the same experience again. The other approach would potentially be taking that pre-medication, like Susan mentioned, with the the heavy ibuprofen, getting a stronger narcotic if you need it. And sometimes it’s just going into it knowing these are gonna be the absolute worst cramps of my life. And they last for a limited time. And usually at the point that they are the worst is oftentimes when they start to get better shortly thereafter because what makes them hurt so bad is that there is a relatively large object going through a relatively small area. And once that passes, it gets better very quickly, actually. That may be something that helps you as you’re you’re going through it, knowing that there’s other ways you can deal with it. But keep the faith. This is hard. And I always say that patients with miscarriages have a much tougher time because they don’t relax until much later in the pregnancy compared to patients who have straight up infertility where they can’t get pregnant. And for those patients, they get a positive pregnancy test and life is good. For patients with miscarriages, you hold your breath for much, much longer.

All right, what’s our next question?

Susan Hudson MD (34:49)

Okay, hello ladies. I’m 27 years old with PMOS and just went through three medicated IUI cycles with frozen sperm. The first two were unsuccessful, but on the third cycle I had a faint positive on 14 plus 15 DPO and then got my period. Should I consider that a chemical pregnancy? Should I not even count it at all? Was it a fluke with the trigger shot? My HCG was three on 14 DPO.

Been trying to conceive for two years, one pregnancy after four rounds of letrozole, ended in a mismiscarriage at seven weeks, and have not been successful since, even with the IUIs. Any ideas of what to do next? Tubes are open, sperm is normal, labs are normal with the exception of high testosterone and high AMH, large number of follicles.

Carrie Bedient MD (35:36)

So what do you think about chemical pregnancies? Did she have a chemical pregnancy?

Susan Hudson MD (35:40)

I would say at 14 days post-ovulation, I would consider that a biochemical pregnancy. By then your HCG level from the trigger shot has usually dissipated enough that it shouldn’t be identifiable on a pregnancy test. if this would have been six days post-ovulation.

I would say that was probably an HCG trigger. In this situation, I do think it was a chemical pregnancy. I think that the fact that now you’ve had two miscarriages, I would do a recurrent pregnancy loss evaluation. Strictly speaking, by some guidelines, it would not fit the definition. But I think most reproductive endocrinologists would probably do that evaluation in a heartbeat. If you’re seeing a general OB/GYN, they’re probably going to be a little bit more resistant about that. But I would do the evaluation. Let’s find out is there something structurally in the uterus? Do we all have normal chromosomes? Do you have antiphospholipid antibodies? Is your prolactin normal? Is your TSH normal? We want to make sure everything’s taken care of. Now, it could just be it wasn’t developing normally, chromosomally abnormal embryo implanted and decided, hey….this isn’t gonna be normal and decide to to go away. And that’s a possibility, but I would dig deeper at this point.

Carrie Bedient MD (37:03)

When you ask about any thoughts on what to do next, I think having achieved a pregnancy, even if it was a biochemical with letrozole is a good sign, I would make sure that you are as tuned up as you can be. Weight is often the big subject here and insulin resistance, because the more weight you are carrying, the higher your insulin resistance is, and that can have a negative impact on getting pregnant and remaining pregnant. I would take a look at that.

and see if there’s anything you can do to adjust there. The other thing that I would consider is is it time to bump up the treatment to either ITI or to bump to IVF? Because while we want you to get pregnant by the easiest way possible, we also don’t want to be doing letrozole cycles forever and ever Amen. That doesn’t serve you and it doesn’t serve your cause. That may be something to consider as well. But for better or worse, there there tends to be a lot of room for optimization with PCOS, but it is a very difficult optimization to do because you’re trying to regulate your metabolic environment in a way that you can’t necessarily control super well. Even patients who are exceptionally disciplined about eating and exercising and following whatever set of instructions they are following. PMOS, it’s a pain in the neck.

There’s pain in the ovaries, really. That’s one thing to to consider about moving forward.

Susan Hudson MD (38:24)

Absolutely.

Carrie Bedient MD (38:25)

All right, next question. I’m 40 and I’ve had two miscarriages, one natural and one after transferring a 4AA euploid embryo. After the second loss, I asked about parental karyotyping, but my RE said it didn’t make sense since we already had embryos. I don’t understand why this isn’t done earlier with all the other testing, especially with a miscarriage history. If one of us has a balanced translocation, insurance would have covered PGTSR and we might have avoided another loss in the 2500 for PGTA. This is our last embryo.

I’m on Lupron estrace about to start PIO, a week from FET. You always say you want patients to believe in their transfer, so why wouldn’t my REI check karyotypes first for peace of mind? Would this cycle be canceled or delayed if I want testing?

Let’s start with the karyotype question. So a karyotype is a test, it’s a blood test that is typically done on both men and women, and it evaluates do you have 46 chromosomes and are they arranged appropriately? What we’re looking for here is essentially a bunch of X’s that look like very clean X’s. We don’t want X’s that have a really long arm on one side, that are missing one on the other side, that you can tell.

They got chopped off and glued on in another spot because those are considered to be translocations. Why that is relevant to miscarriages is that someone can have a balanced translocation. And a balanced translocation means a little bit of chromosome A and a little bit of chromosome B got swapped, but the person has the correct amount of genetic material. It’s arranged a little bit differently, but they have the correct amount.

Where that is a problem for getting pregnant is because that correct amount, when you divide it exactly down the middle and you separate out those two chromosomes, when they divide up and go into the baby or into the embryo, you may not have a balance anymore. We see a disproportionate number of losses when someone has balanced translocations, because most of the time that balance will be uneven, the body will recognize it as an aneuploidy.

Too much, too little, and they will and the body will say, Nope, no implantation, no growth, we’re done. So that’s what a karyotype is. Now, Susan, why don’t we do them on absolutely everybody?

Susan Hudson MD (40:31)

Well, we don’t do them on absolutely everybody. Number one, they can be an expensive test if they’re not covered by your insurance. Number one.

Carrie Bedient MD (40:39)

Like pushing a thousand dollars in certain places kind of expensive.

Susan Hudson MD (40:44)

And it’s not part of a basic fertility evaluation. The other thing I’d like to say is when you’ve had somebody who’s only had one miscarriage, again, it’s not indicated. After two, you can do it. Now I have had two patients that I can remember off of the top of my head actually both of them had essentially unexplained infertility. And we ended up doing IVF. And the way that we ended up figuring out that they actually had a balanced translocation is funny. On both of them, they made a ton of embryos. Like we had something ridiculous, like 10, 15 embryos to be biopsied on both of these people.

But what you saw was they had a few chromosomally normal embryos, but most of the other embryos, they all had abnormalities that were similar. When I get the PGT report, I’m not just looking to see how many chromosomally normal embryos do I have. I’m looking to see is there a pattern.

in something do I have all these weird abnormalities involving chromosome 15 just picking a random chromosome and those are people that in in those two circumstances we went and did chromosomes and we did find that one of the partners and they hadn’t had a history of miscarriages. They just had a history of not being able to get pregnant.

They were creating embryos. Those abnormal embryos were not implanting. And that’s the reason why they weren’t getting pregnant. So they went from unexplained to explained. But that’s also part of the whole IVF is not only therapeutic, but it can also be diagnostic. There’s things that we can learn as we go.

Carrie Bedient MD (42:39)

When you ask about why wouldn’t your RE do this for peace of mind, sometimes it’s the straight up financial component, sometimes it’s the delay because karyotypes take longer to come back. Around here it’s a solid three to four weeks. I tell people that from the get-go of get this one drawn as soon as you can, because it’s going to be at least a month before we have these results. It’s ultimately not going to change what you do.

Most likely, because you already have another euploid embryo to work with. And even if you see that there’s a translocation, you already have the PGT testing, which shows that at a at a bare minimum, the embryo has also a balanced translocation, which is what one of the two partners has as they’re walking around trying to get pregnant. And so it’s not ideal to pass along a balanced translocation, but there are many cases where that’s what we do because that’s the embryo that we have that we can get to stick. So it usually doesn’t change anything. Now I have also had patients over the years where we just get unexplained loss after unexplained loss and we do a karyotype even with euploid embryos and we find that there’s some very minor kind of funky inversion or some distinguishing feature about the chromosomes that can give an explanation. Those cases are pretty rare. And if you really want to do the karyotype, you may be able to. Some docs are very militant about I will not order any labs that I don’t think are necessary. Others will recognize more peace of mind and and may order it.

But the default reason is they’re expensive, they take a while to come back, and they’re ultimately probably not gonna change a whole lot of what is going on with your immediate next transfer. And even with a future cycle, the dosing is gonna be the same, decision to do testing is gonna be the same. You might do PGTSR to identify which ones are carriers and which are not, but functionally it’s probably not gonna change very much at all.

Susan Hudson MD (44:38)

Agreed.

Carrie Bedient MD (44:38)

All right. Those questions are really good questions to deep dive into some of the issues surrounding pregnancy loss. So thank you so much for those who wrote in for those. I don’t think you realize how many people get benefit from hearing those stories and just knowing there’s other people out there who are going through the same thing that they are going through. So thank you so much for writing in your questions and thank you so much for spending part of your day with us.

Susan Hudson MD (45:03)

If you enjoyed this episode and learned something, subscribe, leave a review, and send us your questions at fertilitydocsuncensored.com.

Carrie Bedient MD (45:10)

If you want even more fertility information, pick up a copy of the IVF Blueprint, which is our practical guide to understanding fertility treatment, IVF, and the decisions you’ll face along the way.

Susan Hudson MD (45:19)

Before we go, remember this podcast is intended for education and entertainment only.

Carrie Bedient MD (45:23)

Well, we are fertility doctors, we are not your fertility doctors.

Susan Hudson MD (45:27)

Nothing we discussed should replace medical advice from your own physician who knows your individual history and circumstances.

Carrie Bedient MD (45:33)

Thanks for listening. See you next week. Bye.

Susan Hudson MD (45:37)

This podcast is sponsored by ReceptivaDx. When fertility questions remain unanswered, ReceptivaDx helps reveal why. Trusted by fertility specialists for over a decade, ReceptivaDx identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, ReceptivaDx helps women and their physicians make more informed treatment decisions and move forward with confidence.