I’ve Been Diagnosed with a Miscarriage: Now What?

Today we discuss a sad and sensitive topic: how to move forward after being diagnosed with a miscarriage. 

We discuss:

• the epidemiology of miscarriage

• the treatment options once a miscarriage is diagnosed

• special circumstances such as euploid embryos and pregnancies of unknown location

• potential next steps in terms of testing and/or treatment

• finding emotional support to deal with the grief and move forward along the fertility journey

As always, please keep in mind that this is my perspective and nothing in this podcast is medical advice.

If you found this conversation valuable, book a consult call with me.

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Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.

In Gratitude,

Dr. Erica Bove

Transcript:

Hello, my loves.

Welcome back to the Love and Science podcast.

Today we're going to talk about a sensitive topic and a very sad topic, which is early pregnancy loss.

Now the American College of OB/GYN defines early pregnancy loss as a loss that occurs up until 12 weeks and six days of gestation.

So really focusing on the first trimester.

I understand that you may be listening to this episode and you've had a later loss, a second trimester loss, a third trimester loss, and I know how devastating those can be as well.

So that's also a very broad but different topic.

And so if that is you, I see you, I'm here for you.

We can have a conversation about it.

Today is really going to focus on the most common kind of loss, which is loss in the first trimester.

On a personal note, I've experienced this personally while trying to take care of women who are pregnant and having normal pregnancies.

So I know on a personal level how very devastating this can be.

I also know that there's not really a perfect solution for how to resolve an early loss.

And that's really what I wanted to talk about because, you know, I've been there myself.

I am an REI who unfortunately diagnoses miscarriages more often than I would like.

It's just so sad when this happens, especially when the pregnancy is so highly desired.

You know, and it's always just such a question like, what do I do next?

Like what do I wash and wait?

Do I take medications?

Do I do surgery?

Like what are the benefits of each approach?

What are the risks or disadvantages of each approach?

And, you know, how can each person make the best decision for them?

Right.

And I do think this is a very personal decision.

So that's really what I want to talk about today is sort of understanding the science and how very common, unfortunately, miscarriages are.

And then also talk about the various options for moving forward and getting the body back to baseline.

So that, you know, a person can move forward in their journey with their values impact, with getting as much data as they feel they need, if possible, moving forward and really focusing on the bridge through so that a person can make their next right thing, their next steps with their REI, again, possibly with my perspective as well, to help people get back, you know, into it if they feel they're ready to do that emotionally and not lose too much time for the process.

So let's start by talking about the epidemiology of early pregnancy loss.

We know that approximately 50% of cases of early pregnancy loss are due to chromosomal abnormalities. 95% of these are thought to be derived from the egg and egg energy issues.

But 5% are thought to be related to sperm issues, anyplace and such.

There's also losses that can happen due to translocations.

And so, you know, if you're listening to this podcast and you've had more than one miscarriage, for instance, and it's all been unexplained, you know, that's sort of a slightly different conversation in terms of what is the evaluation for recurrent pregnancy loss.

If that is you, I did record another podcast episode on recurrent pregnancy loss specifically, so please do see that episode.

But we also know that as we as women age that we become less efficient with time.

You know, it's harder to get pregnant, it's harder to stay pregnant, and that is largely due to these inequality issues.

You know, if I see somebody who's in their 20s, there's about a 15% chance of early pregnancy loss.

If somebody is 35, there's about, you know, 40% chance of loss.

And if they're 40, it jumps up to 80%.

And we're talking, of course, in tested embryos, but still.

And if somebody is 45, I have taken care of several women in my career who were, you know, 45 years old, the miscarriage risk at that point is 80% if they're pregnancy persons.

So it's one of those things where, unfortunately, age is not, time is not kind on us, you know, in terms of all of us aging.

And the older we are, the more likely we are to have a miscarriage.

Now, you know, a lot of this is sort of in the outside of genetic testing of the embryos.

However, even 5 to 10% of people who are pregnant with euploid embryos will end up having a loss.

And so, you know, again, I'm on this mission to educate and empower, I think that there's this fallacy that we just have to get to the euploid embryo and everything else will be okay.

And I, you know, I always tell my patients and my clients like, hey, like, you know, there's embryo confidence, there's embryo factors involved.

And so just know in the realm of possibilities that if you have a euploid embryo, you still could have a loss.

I think, you know, if a loss happens, and that's not even in the in the radar of somebody, you know, it can be, you know, even especially devastating.

So I always say, you know, there's a 90 to 95% chance it's pregnancy is going to continue, but we gotta watch it closely and do everything we can to make sure that, you know, all the building blocks are in place, like the hormones and such.

So, you know, that's really the epidemiology of early pregnancy loss.

Now, say this is you or say this has happened to you, and you go in for your ultrasound, and the ultragenographer puts the probe in and say there's an embryo there, but there's no heartbeat.

What what next, right?

Well, I would hope that a physician would come in at that point and have that conversation.

And the New England Journal of Medicine actually has criteria for when a pregnancy loss is sort of suspicious is suspicious for early pregnancy loss versus when it's actually diagnostic.

And that has to do with various factors like the size of the embryo, how many millimeters the size of the gestational sac, whether there's a yolk sac or not, and like, you know, then sort of when a person would come back for assessment would depend on if it's sort of in that suspicious for but not diagnostic.

Another ultrasound might be helpful, you know, in 11 to 14 days.

And sometimes for my patients, I even extend that to seven days, because it's just so anxiety provoking to get another look and really see if there's many interval growth or if there's anything else that would make this more this highly desired pregnancy, you know, possibly viable, right?

We would never want to overcall a loss and intervene, that would be terrible.

So really, you know, it's a hard, hard space to be in, because I think that we all want clarity, we all want to understand the truth of what's going on.

I also will say that a lot of times in these situations, there is ambiguity.

And even if you've had an embryo transfer, the question is, well, was it a delayed implantation?

And the dating is just not exactly what we thought.

You know, if we bring a person back in a week, is there going to be interval growth?

And I mean, I've seen that.

I've certainly seen, you know, embryos that were measuring smaller than I would expect without a heartbeat, when I would expect and then you bring that person back a week later, and, you know, all is well.

And I mean, I think there's this thought that the window of receptivity is probably wider than we realize, and an embryo can hang out a long time in there before implanting.

And if the interval growth is fine, then, you know, then that's okay.

But I know it's a really, really hard time to wait, to understand more information.

But as I tell my patients and my clients, like tincture of time is the only thing that is going to keep open that hope that there maybe is something that is going to continue, that there's a viable pregnancy there.

But also, you know, not dragging it on so long that if it truly is not viable, that there's not false hope there either.

I think it's a really hard balance.

So, so, okay, so let's, you know, sort of get to the point where it's like, miscarriage has been diagnosed, say it's very clear based on New England Journal of Medicine criteria, the embryo is big enough, there's no heartbeat.

It's not expected that there's going to be a heartbeat if another assessment is done.

You know, what are the options?

So one option is expected management.

It's estimated that, you know, obviously, in somebody who's asymptomatic, without any signs of hemorrhage or infection, that if somebody is left alone for eight weeks with, you know, a pregnancy that is not viable, actually 80% of those pregnancies will pass without any intervention.

When I think eight weeks is way too long for me to think about, and honestly, I don't like thinking about pregnancy tissue inside and potentially, you know, sort of creating an item of infection and all those different things.

So in my practice, I usually offer people up to two weeks for expected management, if that's what they desire, because about 50% of pregnancies will pass, you know, during that two week period of time.

And so if people really don't want any intervention, that that seems to be much more palatable in terms of the amount of time.

But then also, it sort of balances like, okay, you know, if this isn't going to happen on its own, let's get things moving along, because most people want to move forward with some next phase of treatment, right?

And it can take time, I mean, beta-HTGs, especially if they're very high, even like a lot of times, either over 10,000, right?

It can take a long time for those levels to come down.

So, you know, that's really the first option is expected management.

And I think, you know, the benefit of that is there's not really any side effects, because there's no medications given, and there's no surgical intervention, you know, if it works, and, you know, it's sort of like the most hands off way to proceed.

But the downside is, it's also the least effective.

And so, you know, in somebody who doesn't want to think about having the pregnancy inside, they just want it out, they want to sort of return to some sort of someone's baseline.

And I mean, I understand that it's hard to carry around, you know, pregnancy, that's not viable.

And, you know, that's sort of not the best option for those people.

So then, you know, the next category of interventions is medical management.

I'm old enough that I used to give mesoprostol alone.

But in the last few years, there's clear data that adding mifepristone is sort of better in terms of the chances that the pregnancy will resolve.

If you give a person mesoprostol, basically, that's a prostaglandin analog, and it stimulates uterine contractions.

And I mean, we use it actually in labor augmentation as well, like, it's a medication that that stimulates uterine contractions in a way that helps to move the process along to, you know, expel pregnancy tissue.

If you use mesoprostol alone, there's about a 71% chance of success, the resolution of the pregnancy with one dose.

And then if there's been like no bleeding or cramping or anything in the first 24 hours, typically, that's when we give a second dose.

And the success rates, I mean, I can't even to say that we're success because it's like not a happy thing.

But if you're looking at like the rates of complete resolution, that's closer to 84%.

Now, I mean, 84%, that still means that 16% of people are going to need something else like surgery, right?

So I don't really love that number 84%.

If you add mesoprostol to that, you can get, you know, up much higher.

Some data is seen as even north of 90%.

So, you know, if you look at the side effect profile, people really don't have more side effects with, you know, mifepristone and mesoprostol together.

Basically, mifepristone is a progesterone antagonist.

And so, because those two medications work synergistically, there's a higher chance of complete resolution if you use both of them together.

And typically, it's the the mifepristone is given.

And then the mesoprostol is given 24 hours after that.

And actually, you know, it depends where you live, though, I will say, because I practice in Vermont, and I live in New York, and we are fairly protected as of yet, on the day of this recording.

But we don't know what's going to come either.

And I know that there are many of my colleagues and friends in other states who don't have these same medications available to them.

So, you know, even in the case of highly desired pregnancies who have, you know, had miscarriages.

So, I just want to say that that is my preferred medical management.

And that's what the American College of OBGYN says is the most successful.

And that's really an option in a patient who's stable, who's not hemorrhaging, who's not infected, but really just wants to augment the process.

For some people, it feels like, you know, a strong period for other people, it feels like even labor pains, it depends on partially on how far along the pregnancy is, and also, you know, a person's individual pain threshold.

But I do think that that can be a good sort of non-invasive option.

The bleeding can happen at home.

I often will prescribe narcotics for somebody to get them through that time, because it's, you know, you can use NSAIDs, but narcotics sometimes are needed because the cramps can be pretty significant.

But it does happen in the context of somebody's own home.

Now, you know, what is the downside of this method?

I will say, like I said, well, it's not available everywhere.

And also, if you are really hoping to have genetic information on the loss, I would say this may not be the best option because invariably the pregnancy passes at 4am into the toilet bowl, and that tissue is really hard to recover.

If you do want to try medical management and send the tissue out for analysis, get a sterile cup from the clinic before you leave, the tissue should go into that sterile cup, and it also should be refrigerated to reduce the risk of, you know, bacterial overgrowth in that sample.

So those are kind of the things to do.

And also, make sure that you're clear with your doctor that you really want genetic tissue sent if this is you, because I cannot tell you how many times I've seen somebody say, "Oh, well, you know, people just said this is my first miscarriage, and, you know, we don't really need to get the testing on it."

But number one, that's really hard for closure.

And then number two, I see people who have had two, three, four, five losses, and there's like this resentment, like, "Well, I know this is my fourth loss, but why did somebody not offer me genetic testing with my first?"

I mean, sometimes we find translocations in the products of the conception.

Sometimes we find other things that sort of help us understand the why of things.

You know, if it's a eupolite embryo, right, then sometimes we look more at the environment and the uterus.

And so as an REI, and somebody who helps a lot of people with recurrent pregnancy loss in my practice, I think that genetic testing can be very useful.

I wish insurance covered it.

Insurance doesn't always cover it.

So I've had people pay, you know, hundreds and sometimes thousands of dollars out of pocket for this testing, which is, as everyone listening knows, fertility treatment is adding insult to injury with the lack of coverage most places.

And unfortunately, this, even though it's a miscarriage, a lot of times, you know, you think it's more general OB-GYN, a lot of times insurance is not going anywhere.

So just be prepared, there may be a cost to it, but I do think that getting genetic information can be very helpful to try to understand the why of the miscarriage.

So, you know, that's medical management sort of as concisely as possible.

There's some advantages, there's some disadvantages, and there are some people who do tri-medical management will need to go on to have, you know, a surgical procedure as well.

So the surgical treatment of an early pregnancy loss, you know, is a little different.

So there's a couple of different options.

You know, it's one of the benefits of this is that it's relatively quick compared to the, you know, medical sort of having a miscarriage process.

So usually most of these procedures are completely done in about 30 minutes.

I will say there's a lot of variability in terms of like different clinic settings and what people can offer.

Some REIs are able to do this themselves, like we are.

Some REIs don't do this anymore and refer back to the general OB-GYNs.

And so just sort of understanding the medical system where you are and navigating that I think can be very important.

There are different ways to do it.

The American College of OB-GYN says that a suction D&C is the best and that can either be done with a handheld device or actually like in a with an actual suction machine that is connected to a wall with a power source.

Either of those ways is, you know, very equivalent.

I think, you know, if I were the patient, I would want to ask about pain control because that seems to be the one real downside of this sort of process is that, you know, gosh, I remember when I was a resident, I was at Planned Parenthood and we would do these procedures for an entire Saturday and just being the empath that I am and seeing what these women went through.

We did use lidocaine on the cervix, but we didn't have any other options for pain control.

And I still think about those patients and just how hard that was, especially for people who really did feel what was going on.

So I just say that to say that, you know, if it were me, I would want like actual pain control, which there's varying levels of that.

I know most of my listeners are doctors, you know, that you can take various pills to have an office procedure, but there's also sometimes when you could say, you know, I just really don't want to be awake for this.

Like I really want general anesthesia.

I mean, if it were me, I'm just going to put it out there.

And I know this is, this is my perspective, not medical advice.

I would want to be out for this procedure.

So short, I know I need a driver, but still.

But it's, you know, it's the uterus doesn't like to be disturbed.

And it's such a sad procedure that, you know, there are ways, like, I think that from my perspective, anesthesia can really be beneficial.

So that's, that's just my two cents.

I'm pretty opinionated about it, but I'm just going to say that I think we torture women.

And if men were in the same situation, that would be much different, much different pain, pain control.

So, so I will say that.

So the downside is there's pain, I think, you know, sort of the upside is that if you opt for a surgical treatment of a miscarriage, the resolution is about 99%.

So, you know, like, if you're thinking about, I just want to go in, get this taken care of and never have to think about this again.

Most people who have a surgical procedure, whether it's a suction D and C in the office or a suction D and C in the OR, like most of the time, it's a complete resolution and people can move on.

This is actually the preferred method.

If somebody comes in hemorrhaging or unstable or infected, because it's the quickest way to get the tissue out.

I mean, when I was a second year resident member, my attending told me, like, learn this skill, because you will save lives this way.

And I really do believe I have because, you know, unfortunately, sometimes people do come in hemorrhaging or, you know, infected and really that is what they need to move forward.

But, you know, most of these happen, you know, not more dramatic setting.

And there are options.

What I would say another downside of the surgical treatment is that, you know, it's instrumentation of the uterus.

And so, theoretically, there is a greater risk for scar tissue to develop.

And, hey, I'm an REI, I treat achermans.

I wish I could give you a number of like, what is the absolute risk of scar tissue inside the uterus after a DNC.

I have not found that in literature.

I think it really does.

Like, there are some procedures that are thought to have a greater risk than others.

The worst achermans that I've seen personally has been after like postpartum DNCs when people are doing this to really like, save their life.

Or, you know, like, sometimes even like a myomectomy when the fibroids are kissing, and then there's the raw edges next to each other that can create really sort of bad scar tissue.

Usually if somebody has a DNC that's, you know, sort of more vigorous, or for some reason that person forms more scar, it's usually kind of on the more mild end of achermans.

Maybe it's in the corner, or maybe there's a band that just needs to be broken up.

It's usually not complete cavity obliteration, but I have seen that before.

And so, you know, it's I would imagine it's under 5%, you know, based on my own personal experience and all the patients I've seen, and there's some suggestion about in literature, but I can't give you an exact number.

I would just really make sure that the person who's doing the DNC knows that you desire future fertility, that you're really wanting a gentle DNC as much as possible, like obviously get the tissue out, but, you know, nothing extra.

There's a lot of like in the opera ports, you know, talks about like a gritty sensation of the uterus, like there's there's none of that.

And I think as REI's we understand that intuitively, I think OBGYNs are so used to saving people's lives in various contexts that, you know, sometimes it's helpful to just put in a plug for like, hey, please be as gentle as possible.

When I do these in my practice, I actually use ultrasound guidance, which is really nice, because then, you know, sometimes all I need to do is one or two passes, and then the tissue's out, I don't need to keep going in over and over and over again.

And so really, the goal is like the least amount of instrumentation possible to, you know, accomplish the task at hand, which is getting out the pregnancy tissue, which can very easily be sent for, you know, analysis, by the way.

So if you're really want genetic testing, it's just like sent right from the OR to the genetic company.

And as long as the paperwork's done, usually we can get results.

So that's another benefit.

But, you know, especially if you're going to somebody who may not have that same lens, or just, you know, obviously, it's a certain just have that conversation and just say like, hey, I'm on this fertility journey, I really would like to reduce the risk of ashermans as much as possible.

Like, you know, what do you do to make sure that the technique is as as traumatic as possible?

And just see what they say, because I think that's that is a really important conversation.

So those are the different treatment options to summarize, there's expected management, which works about half the time, if you give people two weeks.

There is Medicaid management, oftentimes with MYSI and MISO, and that works north of 90, over 90% of the time.

And there's also, you know, surgical management with a DNC, and that works about 99% of the time.

But like I said, you know, factors to consider are, you know, you really want the genetic testing?

Do you want to experience the process?

Do you want to be asleep?

You know, and what's the availability?

Also, what can your medical culture community where you are for you in terms of getting this resolved, as much as possible?

And, you know, other things to think about, usually if there's a DNC, doxycycline is given 200 milligrams, like an hour before the procedure.

So just know that that happens.

The question about whether to give ROGAM is actually kind of controversial.

There's more and more data that because there's not even fetal red blood cells in early first trimester, like it may not even make sense to give ROGAM.

And so I think as more and more data are coming out, clinics are adjusting their policies, that maybe saying like, there's really not a risk of allo immunization if people don't take ROGAM.

But again, you know, ACOG still says to give it.

This is really a case by case conversation with your OBGYN and also the place where you're at.

Okay, so let's talk about other particular situations.

What if you're on the IVF journey and this is a euploid embryo?

Like how does that change the conversation?

Well, what I would say is we know that the PGT technology is not perfect.

And so about 2% of the time we get a result that is sort of not correct, which is unfortunate and which that it was 100% accurate.

But as we know in medicine, like there's basically no test that has 100% accuracy.

That's why we talk about sensitivity and specificity and positive predictive value and negative predictive value.

And why I went to an epidemiology conference as a fellow, like all those things really do play into like, what is the likelihood that your test result is actually true.

And if you do find yourself in a situation where you've had a euploid embryo transferred, and you either have like a biochemical loss or an early pregnancy loss, like, especially if it's an early pregnancy loss, I really do recommend trying to get like tissue on that and tissue analysis, because I have seen in my career where the genetic sort of testing of the products conception is different than what the PGT result was initially.

And I mean, there was the closure, it's like, okay, well, you know, the trifecta derm cells or the analysis of them was not accurate.

And now we know this was actually an aneuploid cessation.

And it's like, okay, well, that's really unfortunate, because part of the reason to go through that technology is to screen out aneuploid pregnancies, but you know, if you have an explanation, sometimes it's a little bit easier to move forward than if you don't have an explanation.

Let's see, what else about the euploid embryo?

If it's a euploid embryo, and if there's no testing, or the sort of path comes back that it truly was a euploid embryo, that's, we start to think a little bit more about sort of uterine or environmental problems.

Now, I will say there are plenty of euploid losses that have no explanation whatsoever.

And that is just, it's so hard not to know why it really, really is.

You know, I think that from my clinical hat would say, okay, well, you know, if it's a euploid loss, and nothing is really found as to why, why the loss happened, to do the most thorough investigation of the uterus moving forward.

So whether it's a sonohistogram, a hysteroscopy, always within endometrial biopsy, from my perspective to evaluate for chronic endometritis, that can be really helpful.

I know it's controversial, whether you get anti-phosphoid antibodies at this point.

You know, I think we talk about like two to three losses in a row.

But when we talk about APLS diagnosis, that's usually untested embryos.

In my practice, I usually initiate the evaluation after one euploid loss, or if the loss is untested, but 10 weeks or greater with embryo size.

And so that's sort of what I do.

I don't think it's wrong to ask for that testing, because there is something we can do if we find something.

So like baby aspirin and, and Lovanox, like those things can be given.

I mean, even right now, I can think of somebody who has had multiple losses and, you know, tested positive and, and, and now is doing much better on anti-phagulation.

And so, and gosh, there's so many things in this field that we can't control.

But if there is something that we can find and intervene on, then, you know, I think it's worthwhile to, to prove that.

You should know that you can't get those, you shouldn't get those tests when the beta is still positive.

So it is a little pesky that you gotta wait till the beta HEG is negative so that the test is actually accurate because the HEG can actually cause a false positive.

And then you go barking off the wrong tree.

So again, there's all these different nuances, which I'm sure your REI will know.

But I think just sort of having a euploid loss is especially difficult, the way our minds work, because it's like, well, I screen out the most common cause of why losses happen.

So why did this still happen?

And that's where really like looking at the whole picture makes especially good sense.

Now, I will also say, you know, the sort of example I provided before was a very clear loss situation where the ultranatterer puts the probe in, there's a large embryo, there was no heartbeat, like that is very clear.

It has been my experience that that is really the exception rather than the role.

What usually happens is we scan somebody at six weeks when we expect them to be six weeks based on excellent IV updating.

And we see maybe a gestational sac, maybe not a gestational sac, we don't see a yolk sac, we don't see anything outside the uterus, but it's technically a pregnancy of unknown location.

And so, you know, in OBGYN, I mean, you know, one of the things can actually kill people is an ectopic pregnancy.

So I don't take it lightly to say that we need to follow these very closely.

But from the patient perspective, I think it can be extremely anxiety provoking, because it's like, wait, do I have an ectopic?

Like, we know 2% of IVF pregnancies actually do end in ectopics, especially when that little embryo can float up into the fallopian tube.

So, you know, I think that the ambiguity of not knowing if it is a viable pregnancy or not is a certain type of health.

I think it is especially helpful if you can have your support system in place to help you navigate that process, because the only thing that is going to sort it out is time.

You know, I think that, like I said in the beginning with the New England Journal of Medicine criteria, like, some things are highly suggestive of a loss.

And so I, you know, I think that starting the mental preparations to say like, well, something is clearly not ideal with this pregnancy, you know, it is possible that this pregnancy might end in a loss and starting to kind of prepare emotionally for that I think can be helpful.

I'm not a toxically positive person.

I'm not a fault-tope person.

So I think just that clarity and that sort of understanding of all the possibilities can be very helpful.

But like I said, that waiting is very, very hard.

So just know that that period of time will not be indefinite, like there will be an answer that comes with time.

It just sometimes it can take weeks to sort out.

And it's a really, really painful process.

So that really brings me to my next point that I want to talk about, which is what is the best way to get the emotional support you need while you're undergoing an early pregnancy loss or even a pregnancy of unknown location?

I think the first thing to appreciate and repeat yourself over and over again, always helps me to have somebody tell me this because sometimes I trust other people more than I trust myself working on it, is this is not your fault, right?

Gosh, as women, we blame ourselves so much.

It's like, oh, it's because I ate from the food truck on Tuesday.

Oh, it's because I was in the OR for 16 hours in a row.

Oh, it's because I had that glass of wine at the party and I really shouldn't have done that.

I will tell you, unless you're like sorting cocaine or unless you're engaging in some super high risk activity, what you're doing did not cause the miscarriage.

These are biological realities.

We talked about the epidemiology in the beginning.

Unfortunately, we are just very inefficient as human beings.

We're inefficient in terms of getting pregnant, we're inefficient in terms of staying pregnant, even if we've already gone through the whole process of IVF.

It's taken a really long time to have this highly desired pregnancy.

I would say just reiterate to yourself, and if you need me to tell you, call me up and I'll tell you it is not your fault.

It is not your fault that's happened.

Just sit with that because any self-blame or self-judgment that we have is not going to help us.

It's just going to hurt us.

It's going to prevent us from moving forward.

I think in terms of the way that my brain works, it's always nice to have a clear path moving forward.

Meeting with your RAI as soon as possible and saying, "Okay, once my body is back to baseline, what are the next steps?

Do I need any more treatment before we move forward?

Do I need any more testing moving forward?

Do I need any more tests to be done like anti-vascular but antibody syndrome or uterine evaluation?

What are my exact next steps before I can move forward?"

For some people, maybe if they have few embryos, they might even go into another embryo generation cycle.

There's all sorts of different ways that this can proceed, but I think just knowing, "Okay, what's the three-month plan?

What are my immediate next steps?

What are you going to be thinking about?"

I think that helps because it really does delay the process.

It's a setback for sure, but I think that knowing what the next steps are clinically can really be helpful in terms of just having that sense of agency and saying, "Okay, well, I'm on the path.

I'm still moving forward."

That's the clarity on next steps.

I think if you've had more than one loss or if this was a euplenumbria, that's when sometimes the conversations happen about full recurrent pregnancy loss evaluation.

Sometimes people take parental karyotypes or sometimes there's a more broad look at the whole body.

If I write in a body, sometimes I know some of these things are controversial, but things that we think about, A1C or prolactin levels, again, I just read the entry update.

The authors might argue with some of the things I'm saying, but I really think that just to get the most comprehensive view, if this is the first loss, understanding that most women have had at least one miscarriage and say, "Okay, well, what do I need to be moving forward?"

But if truly this is your second or your third loss or if it's been if it's a euplenid loss, there may be some things to check before just jumping into another cycle.

Lastly, I would say this can be extremely isolating.

If you even look at the word miscarriage, it's like miscarriage.

I miscarried this pregnancy.

I did something bad.

So I think the whole setup is rigged against women and rigged against community.

It is so important to talk with people who understand, talk with people who have been through this before.

At Love and Science, I would say most of my clients at this point have had a miscarriage and people just understand what it is in a very non-judgmental space.

It's hard.

It's hard being on this path.

It's hard not knowing how long it's going to be.

It's hard getting the hope up and then having it crushed when the pregnancy you thought was going to be your baby is not viable and now you have to talk about resolution.

The whole thing is just so, so hard.

But I also think we're not meant to do this alone.

We're meant to have guides.

We're meant to have supports in place.

That's why I love being a coach for people who are in these sorts of situations.

If ever my client has a miscarriage, I try to get them in the same day if possible for a coaching session, if that would serve them.

And also, you know, really sort of holding them up in community because everybody knows the pain and everybody wants to be part of sharing that burden so that every single person can move forward to fulfill their dream of being a parent when that time is meant to be.

So my goodness, we talked about a lot of things.

We talked about the epidemiology of early pregnancy loss.

We talked about once a loss is diagnosed, the different options in terms of expectant management and medical management and surgical management.

We talked about sort of various situations in terms of pregnancy of un-unlocation or maybe uncertain viability.

We talked about if it's a U-plate embryo, how that maybe changes the thinking just a bit.

And also the importance of emotional support and not blaming ourselves and really finding our tribe because it's just so much better when we can navigate these things together.

So I hope this was helpful.

You know, I've been getting a lot of requests to talk more about the science.

They were to say, you know, Erica, you are love and science.

You talk a lot about the love part, but we want to hear more about the science.

And so science, I sort of think about the science every single day and it's kind of second nature to me.

And I also realize it may not be for some of you who are in different fields like cardiology or pathology or whatever else it is.

So I hope this was clarifying.

I hope it was empowering.

I hope that you feel a little less alone and, you know, if this resonates with you and you're like, hey, I want more science, I want more scientific understanding, please book a discovery call with me.

I would love to hear your situation impart my perspective, offer my best scientific interpretation and options.

And again, this is my passion.

This is, you know, part of why I am on this earth is to serve you.

And it would be my greatest honor to help you bridge your pathway to parenthood.

With that, you know, I love you.

And until the next time, stay tuned for more science episodes to come.

Bye.