Miscarriage after IVF treatment

Transvaginal ultrasonography showing a gestational sac with a diameter of 28 mm, corresponding to a gestational age of approximately 7 weeks and 5 days. It contains a yolk sac (protruding from its lower part) but no embryo, even after scanning across all planes of the gestational sac, thus being diagnostic of an anembryonic gestation.

Patients are very excited when their HCG test is positive  ! They are on top of the world that their IVF treatment has succeeded, and they look forward to cradling their baby in their arms in a few months.

However, like any other pregnancy, 10% of all IVF pregnancies are also destined to have medical problems. The commonest problem is a miscarriage; and in some of these, the reason is because the embryo/fetus does not develop properly. This means that even though the woman is pregnant, and the pregnancy tests are all positive, there is no baby. This is a non-viable pregnancy, and many women get very confused - How can I be pregnant when there is no baby, doctor ?

A pregnancy consists of two tissues - the embryonic tissue, which gives rise to the baby; and the extraembryonic tissue, which gives rise to the placenta. In these pregnancies, only the tissue from which the placenta arises is formed properly. The tissue which gives rise to the embryo does not develop at all. This appears as an empty gestational sac on ultrasound scanning. This is called a "missed abortion" - presumably because the embryo is missing. The technical term is an anembryonic ( without an embryo) pregnancy.

In other women, the fetus continues to develop, and establishes a heart beat which can be seen on the scan at 7 weeks. However, on the next scan, this heart beat stops. This is called an IUFD, or intrauterine fetal death.

The commonest reason for a miscarriage is a genetic problem in the embryo, which prevents it from developing properly. This is a random event, and the risk of recurrence is low, which means patients can be reassured that their chances of having a healthy pregnancy for the future are actually quite good! However , older women, and those with poor ovarian reserve, have an increased risk of having a repeat miscarriage, because their eggs  have more genetically abnormalities, which we still cannot test for.

The medical term for a miscarriage is an abortion. Most miscarriages start with vaginal bleeding which is initially slight and painless. This is called a threatened abortion, because the pregnancy is threatened by the bleeding. This bleeding is from the mother, and is not fetal blood. About half the time this stops spontaneously and results in no harm to the pregnancy. At this stage, the most useful test is an ultrasound scan (usually done with a vaginal probe). If a fetal heartbeat can be seen, this means that there is a 95 % chance that the pregnancy will proceed normally. On the other hand, if the ultrasound scan shows that the fetus has not developed properly ("blighted ovum " or anembryonic pregnancy when no fetus can be seen; or a missed abortion or intrauterine fetal death when the fetus is seen but the heart is not beating, then nothing can be done to save the pregnancy.

In such cases, the bleeding progresses, and the uterus starts contracting. This is felt as painful cramps, and the mouth of the uterus ( the cervix) opens. This is called an inevitable abortion (because it cannot be stopped). If some of the pregnancy has already been pushed out by the contractions, this is called an incomplete abortion.

In patients with a blighted ovum, missed abortion, inevitable or incomplete abortion, the treatment in the past was a uterine curettage (D&C) - a short surgical procedure which is performed to empty the uterus and remove the pregnant tissue. However, in women with a missed abortion, a D&C can cause Asherman syndrome ( intrauterine adhesions) if the doctor scrapes the uterine lining too vigorously. Read more at www.drmalpani.com/asherman.htm . This is why these problems are now better treated with medical therapy.  These pregnancies can be terminated medically with mifegest
( anti-progestational agent) and misoprostol ( a prostaglandin). Your doctor will prescribe these for you.

The standard prescription is the following.

Tab Mifegest ( RU-486, Mifepristone), 200 mg, 1 - 3 tablets at one time. This is an anti-progestin.
After 48 hours, take Tab Misoprostol, 200 ug, 4 tablets at one time. This can be taken orally or vaginally.  This is a prostaglandin
You will start bleeding and cramping about 6-48 hours after the Misoprostol tablet.
You can take pain-killers for symptomatic relief

You need to do a check scan one week after the bleeding stops, to confirm the products of conception are completely evacuated.

It can be very hard to bounce back if you miscarry after IVF treatment after a miscarriage !  Lots of patients get disheartened and give up.  They lose faith in God because they feel he has been exceptionally unkind to them. Others blame themselves for the miscarriage and their self-esteem takes a further battering. They believe that they miscarried because they did not rest enough, or because they lifted a heavy weight ; or ate something which was “ too hot”. Many ill-informed relatives and friends also add to their misery by telling them that it was their lack of taking appropriate precautions ; or their excessive levels of “stress”, which caused them to lose their pregnancy.

All these myths and misconceptions just makes a bad situation even worse ! Please remember that nothing you can do can cause a miscarriage. Your fetus and safe and is well protected in your uterus and nothing you can do can harm in.

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.
Interestingly, many patients get even more determined to have a baby after a miscarriage . They feel that if they can carry a pregnancy to 8 weeks, they can carry one to 8 months as well – and the fact that their embryo did implant gives them a confidence boost ! The truth is that the fact you have conceived ( even though you did miscarry) means your chances of having a healthy baby are excellent, so please don’t get disheartened !