Understanding Miscarriage: Pregnancy Loss after Fertility Treatment

A miscarriage can be emotionally or physically traumatic, for the person who experiences it directly and/or for their partner. It is estimated that miscarriages can affect one in eight pregnancies, but the number of pregnancies lost is actually higher than this suggests, because pregnancy loss can occur before a woman realises she is pregnant.

When we actively test for early pregnancy using pregnancy tests and scans, as we do with patients undergoing fertility treatment, we can detect what might otherwise be unnoticed miscarriages. This can add further distress to those already having to cope with the burden of infertility. What does this mean for patients and their treatment outcomes? And is there any treatment that can be offered to these patients to reduce their chances of miscarriage?

The PET event 'Understanding Miscarriage: Pregnancy Loss after Fertility Treatment' tried to tackle this sensitive and challenging topic. Professor Abha Maheshwari, Dr Ashleigh Holt-Kentwell, Dr Justin Chu, and Ruth Bender Atik were the guest speakers, sharing their knowledge and expertise in the field.

Professor Maheshwari, lead clinician at Fertility Scotland and clinical director of the Aberdeen Fertility Centre, described infertility and miscarriage as two sides of the same coin. They both share similar prevalence statistics, both are linked with maternal age, and both can be associated with a feeling of hopelessness and vulnerability, especially as patients tend to deal with them in private. Yet, they differ in their management.

Fertility clinics have a more proactive treatment pathway and approach for their patients, which involves both parties if the patients are a couple. This isn't the case for miscarriage clinics, where a more retrospective and reflective approach is often taken, focusing solely on the patient who experienced the miscarriage. Two major concerns that Professor Maheshwari highlighted are a lack of consensus in both national and international guidelines for dealing with miscarriage, and the difficulty of obtaining accurate and consistent data and information from patients or previous clinics, when assessing a patient's medical history to offer better and more relevant treatment and care.

Professor Maheshwari pointed out that you don't need to have a miscarriage to prevent one. Proactively improving health and lifestyle factors, such as maintaining a healthy diet and BMI, can reduce one's chance of experiencing a miscarriage. She also warned against the notion that fertility treatment protects against miscarriages, and was especially concerned for vulnerable patients falling prey to add-on treatments and their many promises. Do any of these add-ons have merit?

This was precisely the focus of the next speaker, Dr Holt-Kentwell, a clinical research fellow at Aberdeen Fertility Centre and the lead author of a recent review evaluating the data on the effect of add-on treatments on pregnancy outcomes in subfertile women. The purpose of her work is to help evidence-based medicine come to the forefront of decisionmaking and treatment planning, for treating and managing infertility and miscarriage.

Dr Holt-Kentwell looked at several interventions such as anti-oxidant supplementation in men, progesterone supplementation, DHEA supplementation and laboratory-based interventions such as Embryoglue, and found no high-quality evidence for any of them reducing the likelihood of miscarriage. This doesn't necessarily mean that none of these treatments is of any benefit, but the evidence to date does not tend to support their use.

Many of these add-ons claim to improve implantation, which is of course, a key milestone in pregnancy. Can we actually proactively increase the chances of implantation with these interventions, and thereby help avoid miscarriage? To answer this question, we shift our attention towards the embryo and the endometrium. Dr Chu, sub-specialist consultant in reproductive medicine and surgery at Birmingham Women's and Children's Hospital, tackled this question head on.

Dr Chu highlighted the importance of synchrony of timing between the endometrium and the embryo. Working as a senior embryologist, I describe this to patients coming through for IVF as the two needing to be in the same time zone for implantation to happen. If the embryo is ahead or behind the endometrium in development, implantation will fail. In actual fact, this happens two-thirds of the time.

Despite the importance of implantation, we actually understand relatively little about it. As Dr Chu highlighted, investigating human embryo implantation is ethically and practically difficult. So the sobering reality is that there is no effective evidence-based measure to help with implantation. The jury is still out on interventions such as immune treatment. A chromosomally normal (euploid) embryo is thought by some to have a higher chance of implanting – and, once implanted, a lower chance of being lost in a miscarriage – than a chromosomally abnormal (aneuploid) embryo. But preimplantation genetic testing for aneuploidy (PGT-A) is considered a poorly evidenced add-on treatment by the Human Fertilisation and Embryology Authority.

The final speaker was Bender Atik, national director of the Miscarriage Association, who gave a talk on the importance of supporting fertility patients through pregnancy loss. Despite miscarriage rates being higher than we would wish, it still is an individual experience for the patient, and should not be regarded as just another statistic. Everyone deals with and processes loss differently, and while Bender Atik described the isolation, anxiety and even PTSD that can be associated with that loss, what caught my attention most is the wide spectrum of feelings and emotions patients use to describe their experience. From 'shock', 'distress' and 'powerlessness' to 'relief', and considering miscarriage a 'blip' in the fertility journey from which you can move on.

Experiencing miscarriage after fertility treatment seems to be particularly hard on patients, especially as they have struggled to get pregnant. Quotes such as 'Maybe we just have to accept this is the end of our dreams of a family' make the sombreness of these situations resonate, and make us question how can we support patients, family and friends dealing with this double blow.

Support, empathy and aftercare are imperative. Miscarriage organisations and charities do much work in helping people cope with these struggles, and are a great resource and potential option for reaching out anonymously. Our use of language is also very important. What term should we use, and not use? 'Pregnancy loss' or 'failure' are not appropriate in every situation. Being a bit more mindful with our approach and words, for those who need our understanding the most, can make a significant difference in people's lives.

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

The next free-to-attend online events from PET will be:

• When to Stop Storage: Improving Conversations About Unused Embryos (1 March 2023)
• Fertility-Friendly Workplaces? Attitudes to Assisted Conception and Employment (15 March 2023)
• Surrogacy Law: What Is Intended… For Parents? For Surrogates? For Children? (19 April 2023)