Miscarriage and Recurrent Pregnancy Loss - with Dr Lora Shahine

Dr. Lora Shahine, a reproductive endocrinologist practices out of Pacific NW Fertility and authored Not Broken: An Approachable Guide to Miscarriage and Recurrent Pregnancy Loss. She speaks to Fempower Health about important tips to further empower you in your conversations with medical professionals.


Dr Lora Shahine  01:59

Thank you so much for the opportunity. I'm really happy to connect with you.

Georgie Kovacs  02:03

I wanted to meet with you because I'd asked some of my connections who would be the expert on miscarriage and recurrent pregnancy loss. And your name came up. And then I learned about a great book that you wrote called Not Broken:  An Approachable Guide to Miscarriage and Recurrent Pregnancy Loss. And I did read the book. Tell us about yourself.

Dr Lora Shahine  02:26

Thank you so much for those kind words. I really appreciate that. It was a real joy to write that book. I really wrote it for my patients, because it's such an overwhelming emotional and complicated topic to be dealing with - miscarriage. I kept looking for a resource for my patients to provide for them to get those questions answered, and I just couldn't find it. =


I'm a reproductive endocrinologist, which means after medical school, I did residency in obstetrics and gynecology at San Francisco’s University of California and then did subspecialty training and reproductive endocrinology and infertility at Stanford. And so that's really training kind of beyond your typical primary ob gyn to really focus on reproductive health.  A big part of that training has to do with recurrent first trimester miscarriage. It's really common for people to not really know who the real specialists are to focus on recurrent first trimester miscarriage and it really is reproductive endocrinologists.  We really are the focus. 


I happened to do my fellowship at Stanford when my mentor Dr. Ruth Lathi was starting the Center for Recurrent Pregnancy Loss at Stanford. So just the right place, right time, incredible learning. She really brought together a multi disciplinary approach to recurrent loss. Even though we are the specialists, it takes learning so much more about genetics and the immune system and the blood clotting system.


Georgie Kovacs  04:28

Yes. In your book, you talked about so many light bulb moments. If I recall, the first one was women would come in and test positive for pregnancy and they would have severe anxiety and you were like, “Oh, my God, like, this is not, “Yay, I got pregnant.”  It's, “Can I keep the baby?” 

Dr Lora Shahine  05:04

Absolutely. I talk to people about the innocent joy of a positive pregnancy test is really taken away from someone after a miscarriage. What we're taught growing up is that it's easy to conceive, it can happen when we're ready, and that a positive pregnancy test means a baby. 


When the narrative shifts in any direction, like it takes longer to conceive than what you expect, or you have a miscarriage, itself, it’s such a shock.  We don't talk about what can really happen enough. 


I very distinctly remember my first fertility patients in training.  While you're still learning, you are still training, but you are a physician.  I just loved calling with positive pregnancy tests. And I'll never forget the first time I called with a pregnancy test, and the patient just sort of sighed. And I was taken aback.  She said, “Oh, Dr. Shahine, this is really just the beginning for me.  I'm just really not sure what's going to happen.” It was such a learning experience for me. 


Part of having a program for recurrent miscarriage is teaching everybody on the team that we all are joyful and happy with a positive pregnancy test, but to not be surprised if someone's emotions are guarded, and to really walk them through that process and make sure that they know that that's normal.

Georgie Kovacs  06:40

I like what you said earlier, too, because that's something I'm learning. I think when a lot of people think of a reproductive endocrinologist, they think of a fertility doctor. And you know, it's becoming clear that it's broader than that. And if someone is having issues outside of the basics, sometimes going to that specialist early on seems to be key.

Dr Lora Shahine  07:25

Yeah, that's a really important point that you bring up. I think that there's a real assumption that primary care doctors and primary Obstetricians and Gynecologists have a lot of expertise in fertility. And quite honestly, this is not true.


I can speak from my own experience that, in medical school, I did not learn a lot about women's health, in obstetrics and gynecology residency, it was really focused on delivering babies and surgical expertise, as far as women's health is concerned. And contraception was really a focus, but fertility wasn't really a focus. I hope that that's changing and training. 


When anybody goes to see a doctor about fertility issues or miscarriages that they have a really open discussion with that provider about what that provider is comfortable with. Things change so much to that if anybody is really more than five or 10 years outside of training, the recommendations have drastically changed. 


I published my book Not Broken in March 2017. And already recommendations have changed. And I'm working on a second edition because things change so quickly in this field. So unless providers are regularly seeing patients for fertility and miscarriage, they might not feel very comfortable. Having a strategy saying like, “I really want to work with you, but how comfortable are you really caring for me,” is an important topic.

Georgie Kovacs  09:12

I appreciate you saying that because if we women are voicing some of these concerns, it may come across as being disgruntled. But having a doctor in training, say this is what you're trained on and this is what we're not is really important because I hear so many stories about women being dismissed.


You talk about it in your book, too, when it comes to miscarriage and recurrent pregnancy loss. This just echoes why it's so important to not be fearful of the questions. If you're getting dismissed, it could be defensiveness from the doctor of not having the right training. There could be a lot of things behind it. 


I hate to start with something so frustrating, but you started the book with it  - that there's no definitive way to approach recurrent miscarriage. Women need to understand that the starting point is not consistent. And you even said the guidelines are changing. 


When I read your book, I think it was two or more miscarriages that were clinically diagnosed Is that still the guideline because I thought it was three or more?

Dr Lora Shahine  10:28

It’s actually changed. Before 2013, the recommendation was three miscarriages. And we should clarify a clinical miscarriage, meaning far enough along that you can see anything on ultrasound, or have a tissue diagnosis. So this whole area where women are having a positive pregnancy test, and then a late period, or what we would call biochemical miscarriages, that was excluded for years and years and years. 


Before 2013, for an evaluation of recurrent miscarriage, it was really recommended that someone had three or more consecutive miscarriages.  And so if someone had a miscarriage and then a baby, and then two more miscarriages, the doctor could say,” Oh, I just think you should keep trying.” Sometimes people would initiate testing, and treatment before that. But I'm just saying this is what the professional medical guidelines said.


In 2013, the American Society of Reproductive Medicine, which is the professional medical society for reproductive endocrinologists in the United States, like me, stated, “For the purposes of a clinical evaluation, it's okay to start testing after two clinical miscarriages.” And they were very specific about the clinical pregnancy loss is not biochemical miscarriage, but you've seen something on ultrasound, and the pregnancy stops developing or you have tissue to test or see under a microscope. 


I think women and some doctors are still not even aware of that definition, and it's been out for seven years. And it really allowed for more testing. And the reason that the ASRM changed that is because they said, “You know what, the chances that somebody has a miscarriage after two losses is about the same as after three losses. Why not start an evaluation, even though it's unlikely that we're going to find anything?”  If you do find something like a uterine issue you can fix or a hormonal issue that you can treat, you could really prevent that third miscarriage. So that was a really big deal. 


In November 2017, ESHRE, which is the European equivalent of ASRM, came out with extensive updated guidelines and definitions for recurrent loss. They say two or more and they don't necessarily define whether it's biochemical or not.


In March 2020, ASRM came out with a brand new practice committee guideline, defining infertility and defining recurrent miscarriage. It removed the definition of “clinical” from the clarification, and it removed the word “consecutive.” So the definition of recurrent miscarriage according to ASRM, as of March 2020, is basically to pregnancy losses. And they don't have that specificity of having to clarify the tissue diagnosis or an ultrasound diagnosis. This includes biochemical miscarriages.  The fact that they deliberately removed that clarification opens the door. 


It basically says each miscarriage really should be evaluated. It validates the importance of each loss and that it's okay to do evaluations. 

Georgie Kovacs  15:34

That is incredible, because one of the questions that I've been wanting to ask a specialist like yourself is why these guidelines.  I'll give you an example. In New York City, you can't go to a fertility clinic without getting Fragile X tested for and then I interviewed a woman in North Carolina and Fragile X was part of the miscarriage panel. So she had three miscarriages and then found out she had Fragile X!  


How common is miscarriage and recurrent pregnancy loss?

Dr Lora Shahine  16:36

It happens so much more than people really talk about it. When it happens to you, if you haven't talked to your friends about it, you can feel like you're the only person that's ever had a miscarriage, but it's really so much more common - one in four pregnancies.  


There's certain things that put people at higher risk of miscarriage, like advanced maternal age, especially some chronic illnesses, like diabetes, or untreated thyroid disorders will put people at higher risk.  When women are in their 20s, I'd say with a positive pregnancy test, there's about a 15% chance that the pregnancy doesn't continue. When we're in our mid 30s, that's closer to 25 or 30%. By the time that we're 40, it's about a 50% chance. There's so many caveats to that. 


I'm talking about getting to the point where you can see something on ultrasound.  I'm talking about clinical miscarriages. If you include positive pregnancy tests and late period like a biochemical miscarriage, that number can be significantly higher. 


The ability for people to be able to test at home and to follow their cycles and do home pregnancy tests is really empowering, and people can learn what's going on with their body. I just don't think people realize just how common biochemical miscarriages are. It can actually be two or three times a year if people are having unprotected intercourse, and not necessarily tracking that they can have biochemical miscarriages. 


It doesn't mean that there's anything wrong with the person in that, of course, it feels awful. And emotionally, it's a loss and you're trying to start your family. Even a period without a positive pregnancy test is grieving and lost time. And I understand that emotional piece. 


Biologically, human reproduction is so inefficient.  We've learned so much from doing genetic testing on embryos for people who are doing IVF and doing genetic testing on pregnancy losses that do get to a point where we can contest things. If you really include early biochemical losses, it can be as high as you know, 70%. 


I say that as hopefully a positive thing. I do really try to educate my patients that when doctors do say, “Oh, just try again,” that really, you can say it in two different ways. You can say it in a dismissive way, like, “I'm not going to do any testing, you should just try again.” Or you could say, “You know what, it's so common to have miscarriages, it's probably most likely an issue with that particular embryo. The next time that you try, you have a much higher chance of having a totally healthy baby without any intervention.”  


For me, like, doesn't that sound a lot better, because that actually is the science. You know, it doesn't mean that we don't do testing.  It doesn't mean that we don't validate and really think through losses and comparable strategy for family planning. I want people to understand just how common it is. If I can get that information out, it doesn't take away the sadness or the grieving.  It doesn't mean that we shouldn't do testing and take care of everybody. 


When they were first trying to work on getting a home pregnancy test. The NIH was working on this in the 70s, and they were just getting random samples from women every single month around the time of their period from across the United States. When the researchers realized just how common biochemical miscarriages work, that was one of the arguments to not allow home pregnancy tests to be sold and drugstores because they didn't think women could handle that information.

Georgie Kovacs  21:55

I know we can't go through the whole laundry list because you have all sorts of things listed in your book. So for anyone who wants the details, I would encourage you to read Dr. Shahine's book because it's very easy to read. It's honestly a quick read.  During COVID, with a four year old as a single mom, I was able to read it. 


Maybe you can give us some highlights.

Dr Lora Shahine  22:17

There are certain tests that all professional medical societies really do agree on. And then there's a lot of controversial stuff when it comes to testing for miscarriage and recurrent loss. The things that most professional societies recommend testing for our number one, genetic issues as far as a balanced translocation in the people that are getting pregnant. 


Let me back up one second. I just want to clarify the most common cause with first trimester miscarriage is a chromosomal issue in the embryo. 


When you're doing testing and a couple, for recurrent loss, you're testing the people that are getting pregnant. At least 50% of the time or more, I would argue, but the steady state 50%, you don't find anything abnormal in the people that are getting pregnant. 


Before anybody does a single test, I just want to clarify there's a real chance that we're not going to find anything wrong, but I really want to make sure that we're not missing anything else. So it's kind of like setting that expectation. 


The balanced translocation is basically a genetic chromosomal rearrangement and one of the parents that does not impact their own health, but when they go to make eggs and sperm, some of the eggs and sperm are going to be missing big portions of DNA and will result in miscarriage. So it's a blood test. You’re  testing for carrier type. And what you're specifically looking for is a balanced translocation. If we only find it about 3% of the time, it's very rare, but when you do find it, it really does explain a lot of what's going on. 


We look at uterine issues or anatomic issues that can put someone at higher risk of miscarriage. So a uterine septum is a fibrous band of tissue that someone can be born with that can make it a higher risk of miscarriage if the embryos implanting on this a vascular not very supportive tissue within the uterus. Some fibroids put people at higher risk of miscarriage. A lot of people have fibroids and they're not all affecting infertility or miscarriage risk, but fibroids that are inside the uterine cavity, you know where an embryo would implant or significantly large fibroids like 8 or 10 centimeters, those might need to be addressed hormonal issues and look for diabetes, thyroid disease, elevated prolactin those are important things to rule out. 


The one immune issue that's been associated with recurrent miscarriages, antiphospholipid syndrome, and it's a collection of risk factors you can see clinically and then certain antibodies that you can test for in the blood of the mom, that if they're present at the time of the embryo trying to implant, they can really impact implantation. And simple treatments can be aspirin, and heparin, which is a blood thinning medication. 


Other tests that are sometimes done are a semen analysis, just to get a good baseline.   If someone's taking a long time to conceive, sometimes you can find a sperm issue and it can really help with planning. 


Some people will check for antibodies to the thyroid. That's pretty controversial. But if you have antibodies to your thyroid, that might signal that you're not able to keep up as well in pregnancy. 


I have a whole chapter on sort of controversial tests and treatment and pros and cons. So I'm really trying to focus on your question, which is sort of what is recommended and, and so everybody agrees on that. 


But individual doctors will sometimes order different things, and that's honestly, that's why I wrote that book. I wanted patients to be able to advocate for their care and understand it in really simple terms. All the medical references are there including ASRM guidelines, and studies to support why these tests should be done. And so sometimes, people might be able to have a really fulfilling conversation with their physician.  I don't want to ever be tense situation between doctor and patient, but it's okay to learn and have that conversation.

Georgie Kovacs  27:11

The septate uterus. I've heard that it does impact being able to carry a child and that it doesn't. I attended the ASRM conference last year.  It was a US doctor and a European doctor comparing ASRM and ESHRE guidelines around a septate uterus. And what was fascinating is they took several different images, and they said, “Okay, if we compared ASRM guidelines versus ESHRE, would a given patient be diagnosed with it or not? They couldn't even agree on whether or not someone had it! And then it was still unclear if it impacted pregnancy! 


Can you shed light on this because as a woman, I'm observing that the doctors don't even agree on whether or not it matters. Most women probably wouldn't even know what a septate uterus is to even ask their doctor, “Do I have this?”

Dr Lora Shahine  28:16

Absolutely. That is one of the hardest parts about this field. Number one, there are not a lot of really strong, consistent, well-done clinical trials. That's the best way to really get definitive answers and science. They're just not a lot of them there, and that leaves a void. And then patients get stuck in the middle. 


There are absolutely women that have septate uteruses that have their families, so there isn't a complete, “If you have a septate uterus, you're never going to have a baby.” The way I think about it is there's lots of places in the uterine cavity for an embryo to implant. And so if the embryo implants on a wonderful, vascular, healthy uterine lining away from the septum, probably that person is going to have a full-term delivery. If the embryo implants on the septum and it's not very vascular, and it can't really support a pregnancy for very long, they might have a higher chance of miscarriage. 


There are definitely studies that show that if septums are removed, which is a very simple procedure, it's called a hysteroscopy. It's taking a little camera through the cervix, no incisions on the belly, just through the cervix when someone's asleep.  The doctor snips that little fibrous tissue. It's a very low risk procedure that if it has a high yield, it might be beneficial. 


You have to weigh everything. But there are studies that show if someone is having miscarriages, and they have a septum resected, the very next time that they get pregnant, they have a lower miscarriage rate than you would expect for what their history had been to date. Okay, so it's not a perfect test, the perfect scientific clinical trial would be with 200 women. They all have the same number of miscarriages, they all have the same exact diagnosis and image of a separate uterus. Half of them get it fixed, half of them don't. And let's see what happens in the next pregnancy. And that study just doesn't exist. And so it leaves room for doctors to think about things in different ways.

Georgie Kovacs  30:54

The other one I wanted to bring up is the thyroid antibodies. What I hear over and over is the most common test is TSH, yet there is disagreement on what a normal TSH is. I heard at Yale they test the full thyroid panel because they've seen so many Hashimoto’s case