IVF and Miscarriage: Reducing Risks, Providing Support

The most recent PET (Progress Educational Trust) event – 'IVF and Miscarriage: Reducing Risks, Providing Support' – explored pregnancy loss in relation to fertility treatment, including how to reduce risks and provide appropriate support. The event was produced in partnership with the Scottish Government.

Sarah Norcross, director of PET, chaired the event and shared some introductory facts about miscarriage and pregnancy loss. She explained that the usual medical definition of miscarriage is loss of pregnancy before 24 weeks gestation, although some organisations prefer to define miscarriage as loss of pregnancy before viability.

According to the NHS, miscarriage occurs in approximately one in eight known pregnancies, predominantly during the first 12 weeks. However, many more pregnancy losses are believed to happen very early in gestation, before a person is even aware that are pregnant. Losses in the second trimester are rarer, but nonetheless affect three or four percent of pregnancies.

Norcross also explained that people having IVF treatment are likely to find out they are pregnant sooner than people who have conceived naturally, as they will know the date of their embryo transfer and will know the soonest that they can take a pregnancy test.

The first panel speaker was Dr Andrea Woolner – early pregnancy lead for NHS Grampian, and senior clinical lecturer in obstetrics and gynaecology at the University of Aberdeen's Centre for Women's Health Research.

Her talk focused on early pregnancy, and she detailed her work within an early pregnancy unit which sees patients with complications such as bleeding or excessive nausea following a positive pregnancy test. She explained that the pregnancy sac is visible on an ultrasound scan from five weeks gestation. During the following two weeks, more embryonic structures become distinguishable, including the 'heartbeat' from around seven weeks.

Dr Woolner explained that in many cases, women who report with some bleeding go on to have a normal pregnancy. In some cases, progesterone might be prescribed to help.

To diagnose a miscarriage, clinicians often need to look at two ultrasounds – one week apart – in order to determine that the embryo is not developing, rather than the embryo simply being smaller than expected for its gestational age. However, for some people, there will be no signs that the pregnancy is not progressing. Such pregnancy losses may not be picked up until a routine scan at 12 weeks, although IVF patients tend to have an scan scheduled at seven weeks.

The second speaker was Dr Cheryl Dunlop, a consultant in gynaecology and reproductive medicine at the Royal Infirmary of Edinburgh.

Her talk focused on recurrent miscarriage, which the National Institute of Health and Care Excellence (NICE) defines as three or more consecutive pregnancy losses during the first trimester. However, she added that the European Society of Human Reproduction and Embryology works with a definition of two consecutive losses. The Royal College of Obstetricians and Gynaecologists use the NICE definition of three, while advising members that it may be reasonable to begin investigations after two losses.

Dr Dunlop acknowledged that miscarriage patients can experience grief and loss, regardless of whether they conceived naturally or via assisted conception, but added that for IVF patients miscarriage can also cause delays in treatment and this can adding to feelings of lack of control. She also said that recurrent miscarriage can be hard on clinic staff, as there is often no diagnosable reason.

However, Dr Dunlop advised that there are tests and interventions that can help in some (not all) cases. These include encouraging patients to follow lifestyle advice around BMI, smoking and alcohol intake. Certain medical tests are helpful in some cases– for thyroid function, lupus and acquired thrombophilia, as well as scanning the uterus for anomalies. From the third consecutive miscarriage, genetic testing of embryo tissue can also be considered.

Dr Dunlop pointed out that IVF patients may be at an advantage here, because a fertility clinic will have all of these tests to hand, keeping care within a familiar team and setting. Clinics can also provide access to counsellors, early scans and medical support where appropriate.

Dr Dunlop also discussed recurrent implantation failure, when embryo transfers are unsuccessful. These do not constitute miscarriages per se, but can also be upsetting to patients.

The third speaker was Dr Matt Prior – head of department at the Newcastle Fertility Centre, coordinator of the Miscarriage Priority Setting Partnership, and lead author of that Partnership's research priorities for miscarriage.

As part of that priority-setting work, Dr Prior set up a public survey asking 'What unanswered questions about miscarriage would you like to see answered by research?'. More than 3700 responses were received and then categorised (for example, according to whether they related to causes of miscarriage, support, prevention and so on). Some of the responses submitted were very broad, such as the question 'Why are some couples affected and not others?', whereas other responses related to very specific circumstances.

A follow-up survey gave respondents the opportunity to rank questions in order of importance, and the top ten questions were used to inform research proposals. The number one priority focused on preventing miscarriage, while the number two priority focused on the emotional and mental health impacts of miscarriage on the couple. Causation was featured heavily in the remaining questions, encompassing preexisting medical conditions and the genetics of the embryo as well as parental lifestyle and male factor.

The final speaker was Katy Schnitzler – information, research and training lead at the Miscarriage Association and a researcher at the Open University's Faculty of Wellbeing, Education and Language Studies. Her presentation focused on the patient perspective.

Schnitzler explained that for IVF patients, miscarriage can mean a range of different things, including a financial loss or a loss of the chance to become a parent. Hearing people say 'Oh, you can just try again' can be hard at the best of time, and harder still for couples who have exhausted their NHS-funded cycle(s) or have paid large sums for private treatment without success.

She also outlined how being back in a fertility clinic setting after loss, with lots of pictures of babies displayed on walls, can be very hard – especially alongside some professional language such as the phrase 'failed cycle', which may not align well with the patient's feelings.

Schnitzler gave a helpful list of ways to support people who have experienced miscarriage, that are applicable both in the fertility clinic and in life more broadly. She advised mirroring the language that the affected person uses – for example, honouring their choice of words if they say they have lost a baby, a pregnancy or an embryo. Avoid 'toxic positivity', such as saying 'It will work out next time' – this may not be true, can increase feelings of expectation, and can lead to feelings of failure if it does not come to pass. She also recommended being considerate about partners, and attending to nuances around different cultures or sexuality.

After the presentations, it was time for questions and comments from attendees. Some questions concerned the need for repeat scans to confirm miscarriage, and the fact that the wait can be upsetting. Dr Woolner sympathised, but explained that all tests have error rates, and clinicians need to be absolutely certain when dealing with a wanted pregnancy.

There was also discussion around PGT-A, which is not available as part of NHS-funded treatment, but which some sources say can reduce miscarriage in certain patients. Drs Woolner and Dunlop both emphasised that PGT-A can offer no guarantee that a pregnancy will not end in miscarriage, and Norcross added that it can reduce the number of embryos a couple has available for transfer.

Further questions concerned the need for better psychological support for patients. Fertility clinics are required to provide access to counselling, and Dr Woolner said that she would love to be able to offer this kind of support within the early pregnancy unit, but demonstrating that this is a good use of public funds is very difficult. Schnitzler agreed that there is a lack of follow-up care, and observed that people who need support after miscarriage often have to make great effort to obtain it, while going through a vulnerable time.

As well as discussing how to reduce risk of miscarriage and how to provide support, this PET event also highlighted gaps in our current understanding of the causes of miscarriage.

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PET is grateful to the Scottish Government for supporting this event.