The author of this piece, Dr. John Littell, is a family physician who has been practicing for more than twenty-five years. He has seen and treated countless women for a myriad of gynecologic concerns and offers a glimpse into the cultural ramifications of trends in the medical community that women need to know about. Read his other articles here.
A healthy pregnancy culminating in the delivery of a healthy boy or girl. Is that not the hope and expectation when a woman discovers she has conceived a child? Of course it's the best case scenario, yet, all too frequently, women experience the loss of their child through miscarriage early in the pregnancy.
As a doctor who has provided prenatal and obstetric care to women for over 25 years—not to mention having shared with my wife the loss of several pregnancies through miscarriage—I have endeavored to discover all that I could about the causes of pregnancy loss through miscarriage and any possible means of preventing that loss.
I was particularly motivated to share my views on preventing miscarriage after recently meeting a new patient who has experienced the loss of four pregnancies—including one child at 18 weeks gestational age—with no hope of prevention provided by her previous OB-GYN physicians.
You would think that everyone would want to prevent miscarriages, right? You might be surprised to learn that a lot of OB-GYNs today neglect to help women get to the root cause of her miscarriage so that she can have a healthy pregnancy the next time. All too many OB-GYNs gloss over the role that low progesterone levels play in numerous miscarriages and how for many women, prior use of the Pill may play a part. There seems to be a blind spot in the care of many OB-GYNs—one that's very easily remedied—and it's failing women.
Many OB-GYNs do not share my views. After my wife and I experienced a couple of miscarriages, I wanted to get to the bottom of why miscarriages happen so we can prevent them. Many in my field, however, seem to give up on trying to solve the causes. While doing my training in Obstetrics and Gynecology, for instance, I was taught only to “work up” (i.e. further evaluate and possibly diagnose) the woman with repetitive miscarriages after she experienced her third loss. In the field this is known as “habitual abortion” (with the term abortion referring to any fetal loss—“spontaneous” abortion is miscarriage, and “induced” abortion is the term we all commonly refer to simply as abortion. It seemed to me, even early in my training, that there was something wrong with the thought of doing nothing to prevent miscarriage in the woman’s second—or even first—pregnancy. Did not the lives of those desired babies matter? Does not the emotional and physical tumult many women experience matter? And what if the woman or couple were not able to achieve another pregnancy after two losses?
In my OB-GYN training, I was also taught that most early miscarriages are caused by chromosomal defects in the baby—something that some prospective parents are perhaps comforted by, as they view this unexpected loss of the baby’s life as due to a condition incompatible with life outside the womb. This view is still promulgated by the American Congress of Obstetricians and Gynecologists (ACOG) and others.
While physicians caring for those who have suffered miscarriage mean well to be compassionate to moms who are devastated by the loss, if we are giving consoling words at the expense of accurate information and efforts to provide the best care, then we are failing them as healthcare providers. Which is why the best approach, in my professional opinion, is to offer the women and couples hope in the form of a prescription that will help prevent future miscarriages. After several years of practice, and fueled by my personal experience to find answers, I came to understand the true cause of the majority of miscarriages is one that is actually easily preventable. I was studying the emerging science of natural procreative technology, NaPro Technology, in Omaha, Nebraska, under Dr. Thomas Hilgers, a renowned OB-GYN who has a remarkable track record for assisting women with all manner of fertility problems. There I learned that the true cause of many if not most miscarriages is the relative absence of progesterone, the reproductive hormone essential for the life of the unborn child within the womb.
As its name implies, “pro-gesterone” is produced by the woman’s ovary each month in preparation for pregnancy during the luteal phase, the post-ovulatory of second phase of the reproductive cycle. Progesterone, among other properties, improves the blood flow to the baby through the developing placenta. It also prepares the breast tissue for nursing (explaining the breast tenderness experienced by most women in early pregnancy or even prior to each menses).
There are many factors which affect the woman’s ability to produce progesterone. The most common reason women have inadequate levels of progesterone is that they are currently or have recently taken oral contraceptives or other forms of birth control that suppress the normal function of the ovary. This is why OB-GYNs should advise patients to wait 4-6 months before becoming pregnant after a woman has stopped taking the Pill. Reputable organizations such as the Mayo Clinic claim that “the hormones in birth control pills don’t remain in your system” but fail to inform women that the use of BCPs and other hormonal forms of contraception suppress the woman’s natural reproductive cycle and ovulation—so that commonly women do not achieve the normal levels of their own hormones for several months after coming off of BCPs and other methods.
Yet, for reasons likely perplexing to the reader, many OB-GYNS make no mention of progesterone levels when they visit with women in early pregnancy. There are readily available methods of testing the progesterone level in each woman to ensure adequate levels, and there are many ways of administering the hormone to women who have lower levels and hence increased risk of miscarriage. For instance, these progesterone measuring methods and support are standard procedure for IVF babies. So, why aren’t we using these methods as frequently for women who are conceiving naturally?
As with any blind spot in health care, there's no good reason as to why it exists. It's possible the need for healthy progesterone levels is eclipsed by many OB-GYNs tendency to over-prescribe the Pill. Perhaps providers are loathe to voice a con to the Pill, that subsequent hormonal imbalance have been shown to play a part in miscarriage. But given how easy it is to resolve the imbalance with progesterone supplements, this neglect is inexcusable.
Allow me to give you an idea of just how easy this is to implement. In my practice today, my standard operating procedure is to measure progesterone levels in each and every woman who achieves pregnancy—as early as possible in the pregnancy. With the benefit of NaproTechnology, we even measure progesterone levels in women striving to achieve pregnancy. Then, using a standardized curve (values range from 20 to 160 during the pregnancy), we increase a patient’s hormone levels by oral supplement, intramuscular injection, or even intravaginal.
This same protocol is used for the many women who, in recent years, have opted to have a “chemical abortion” using a medication known as RU-486 (mifepristone), which has become the method of choice in many abortion clinics. This medication blocks the effects of progesterone in early pregnancy, leading to decreased circulation to to the developing placenta. Women who experience misgivings about having taken this medication while in the abortion clinic frequently call an “Abortion Pill Reversal” hotline where they can be put in touch with doctors who provide them with sufficiently high doses of progesterone to reverse the effects of the RU-486 and achieve a healthy pregnancy. Whether in the prevention of miscarriage or the reversal of the effects of chemical abortion, there have been amazing success stories for these methods.
It's not that the OB field isn't aware of the role hormonal imbalance plays in miscarriage; in fact they have recently coined the term “chemical pregnancy” to refer to those early pregnancies that are lost through miscarriage due to hormonal imbalance. This language change seems to be out of an effort to decrease a patient's feeling of loss, leading the woman to believe that this pregnancy was somehow “less” of a pregnancy than one that survives the implantation process and beyond. But to me it sounds like the old line about being just “a little pregnant,” as though it were possible. Sadly, this is no joke, and the language change doesn't stop many women from experiencing the loss just as real as any other miscarriage or lost child.
I think these efforts of those in the OB field, whether changing language to “chemical pregnancy” or telling her the miscarriage is likely due to a chromosomal abnormality of the baby (when it may likely be due to the woman’s low progesterone levels), are attempts to minimize a woman’s emotional pain by making it seem like she couldn’t have done anything to avoid it. But the doctor's job is to serve the patient and give her the best possible care, not use linguistics to stretch the truth. I believe to give good care to patients necessarily includes the provision of accurate information so that they can make informed decisions. I feel so strongly about this that it became the premise of my book The Hidden Truth: Deception in Women's Health Care.
The more knowledge women are given by their healthcare providers, the more empowered they are to make the best decisions for themselves and their children. I hope that more health care providers start informing women of the essential involvement that progesterone plays in healthy pregnancy so that fewer women experience the physical and emotional loss of miscarriage.
Photo Credit: Ashley Crawford Photography