Tuesday, March 08, 2011

Why do women who miscarry feel they need surrogacy ?

All doctors know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. This means that the usual reason for a miscarriage is a problem with the embryo - and most women who miscarry have a completely normal and healthy uterus !

However, a patient who had early recurrent pregnancy losses has a completely different world view ! She feels that the fact that she got pregnant in her bedroom means her eggs must be fine. She usually has regular cycles , and since all her blood tests for ovarian reserve and ultrasound scans for follicular monitoring are normal as well, she has medical evidence to back up this belief ! ( Little does she realise how inefficient human reproduction is; and how common random genetic errors are, even in health fertile women ! )

In her opinion, the fact that she could not grow any of her babies in her uterus beyond 8 weeks clearly proves that it's her uterus which is faulty. This is why the "common sense" approach is - let's change the uterus !

It's true that surrogacy seems to be a logical choice - but this logic is flawed ! In reality , the fact that she got pregnant means her embryo implanted successfully, which is very strong evidence that her uterus is normal ! Using a surrogate's uterus will not improve her chances of having a baby at all ! After all, if her uterus is normal, how will using another woman's normal uterus help her ? However, because implantation is a "black box" area which we do not have the scientific tools to explore, there are still a lot of myths and misconceptions which surround the reasons behind a failed pregnancy. A woman who has had recurrent pregnancy losses has very low self-esteem. She naively believes that if the surrogate has had a normal birth in the past, this proves that her uterus and her body works better than her own - and this is why she chooses surrogacy as a treatment option.

In reality, she would be much better off using donor eggs or donor embryos ! Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus; or whose uterus is irreparably damaged ( as proven by hysteroscopy).

Sadly, most doctors will not bother to educate her ! They are quite happy to do surrogacy for her, because this is much more profitable for them !


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7 comments:

  1. This is true for the most part, However, as an immunologist, I would have to point out that a small subset of women with a healthy uterus and a normal embryo still can be at risk for significant pregnancy complications if they suffer from autoimmunity.

    While NK cell and Th-1 mediated to pregnancy is still controversial, nobody can argue anymore that certain autoantibodies are most definitely linked to pregnancy loss. For example, anti-phospholipid antibodies that often result in second trimester loss, or anti-ro/la antibodies linked to congenital heart block in babies. While a lot of this is treatable and can be managed in unarguably high risk pregnancies, there are some women where possibly the battle against their immune system cannot be won. I know a couple of cases of women who have had 4-5 losses between 12 and 20 weeks. In such women, it is unlikely to be chromosomally abberent eggs, especially when a products of conception test establishes that the embryos were chromosomally normal.

    Such women should be given the option of surrogacy IMO, but these are, thankfully, a rare group.

    ReplyDelete
  2. I agree that the option should be offered . My point is only that this group ( women with recurrent pregnancy loss who really need surrogacy for medical grounds) is very small !

    Also, a normal chromosome report for the products of conception does NOT rule out a genetic problem. Lots of genetic problems are very subtle and will not show up on a chromosome study.

    The rule, " If you hear hooves, think of horses, not zebras ", still applies !

    Dr Aniruddha Malpani, MD
    Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
    Bombay 400 005. India
    Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

    Helping you to build your family !

    PS Watch our infertility cartoon film at http://www.ivfindia.com

    Read our book, How to Have a Baby - A Guide for the Infertile Couple,
    online at www.DrMalpani.com !

    Read my blog about improving the doctor-patient
    relationship at http://doctorandpatient.blogspot.com/

    ReplyDelete
  3. Yes, thankfully the percentage of repeat late miscarriers is indeed tiny.

    But I think once you move into the second trimester, where organogenesis has been completed, the chance of a genetic abnormality driving the loss becomes really minuscule, especially if the in-depth ultrasounds they do at week 16 and 20 show that organ development did indeed occur normally, and you find that the chromosomes are normal by karyotype.

    The exception where genetics can drive loss in the 2nd and 3rd trimesters, is often in the case of a genetic mismatch between the mom and dad- I attended a fascinating journal club (a paper in the Journal of Clinical Investigation) which basically showed that certain rare HLA (I think) pairings between the mom and dad create a very high risk scenario for pre-eclampsia and also pregnancy loss, and that is NK cell driven. The study was basically talking about genetic screening for risk. If it is identified, an egg or a sperm donor might be considered.

    ReplyDelete
  4. I agree that a better option for these patients is to use donor gametes, rather than to use a surrogate.

    It's complex and confusing issue - and causes a lot of heartburn for doctors and patients as well.

    We all have our personal worldviews - and the prisms we look at the world sometimes distorts reality, so we end up seeing only what we want to see !

    Dr Aniruddha Malpani, MD
    Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
    Bombay 400 005. India
    Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

    Helping you to build your family !

    PS Watch our infertility cartoon film at http://www.ivfindia.com

    Read our book, How to Have a Baby - A Guide for the Infertile Couple,
    online at www.DrMalpani.com !

    Read my blog about improving the doctor-patient
    relationship at http://doctorandpatient.blogspot.com/

    ReplyDelete
  5. Aruna1:12 PM

    Hello Dr.Malpani,
    I am a 33 year old woman from Bangalore. I have suffered 3 recurrent miscarriages in the last 7 years because of autoimmune disorder that showed in blood tests for Lupus Anticoagulant being highly positive although I do not have any SLE. In all 3 pregnancies I the fetal growth was retared by 18 weeks due to very high blood flow resistence in both the uterine arteries although I was on high dose fragmine 5000 units twice a day in the third one. Now we have decided to try surrogacy as the final attempt. I would like to know that because I coud concive naturally first 3 times, is the chance of IVF cycle being sucessful be high . Request your opinion on this.

    ReplyDelete
  6. 'A woman who has had recurrent pregnancy losses has very low self-esteem.'

    Please... this is a very narrow minded view. I have now had 6 miscarriages and one ectopic. We also have a very healthy 5 yr old girl. And I have a very healthy self esteem. It is rude and ignorant to suggest that women who've had recurrent miscarriages have a low self esteem. I think if you are working with women who have had these experiences you need to be more respectful.

    ReplyDelete
  7. Dear Lauren,

    Thanks for your comments.

    I agree it's unfair to generalise, and there will always be exceptions, but lots of studies show that most women who have miscarried do suffer from low self-esteem . They feel their bodies have let them down.

    ReplyDelete

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