March 19, 2026 • 38 mins
Why does miscarriage keep happening even when everything appears “normal”?
For families navigating recurrent pregnancy loss, the most painful part is often the unanswered questions. Being told it’s “bad luck” or “unexplained” can leave parents feeling confused, frustrated, and searching for deeper answers.
In this powerful and in-depth episode of Cry It Out Loud, we’re joined by reproductive endocrinologist Dr. Ryan Martin to break down the real medical causes behind recurrent miscarriage and the critical factors that are often overlooked.
This is not a surface-level conversation. We go beyond basic explanations and into the complex science of pregnancy loss, helping you understand what may actually be happening in your body. In this episode, we explore:
- When recurrent pregnancy loss should be fully evaluated and whether waiting for multiple miscarriages delays care
- What “chromosomal abnormality” really means, including aneuploidy vs. inherited conditions like balanced translocations
- The role of sperm health and DNA fragmentation in miscarriage and embryo development
- Why miscarriage can still happen after IVF, even with genetically tested embryos (PGT-A)
- Uterine factors that may be missed, including septum, scar tissue (Asherman’s), and fibroids
- How endometriosis and chronic inflammation can impact implantation and early pregnancy
- The truth about immune-related causes of miscarriage, including antiphospholipid syndrome and autoimmune conditions
- The role of progesterone and luteal phase defects in early pregnancy loss
- How thyroid function, insulin resistance, and hormones influence pregnancy outcomes
- The emerging role of epigenetics, stress, and environmental factors
- What “unexplained recurrent pregnancy loss” really means and the limits of current testing
- When to see a reproductive genetic counselor and what advanced testing may provide answers
If you are navigating recurrent miscarriage or pregnancy loss, infertility, IVF failure, or pregnancy loss without clear answers, this episode will give you deeper insight, clarity, and validation.
Your loss is real. Your questions are valid. And you deserve more than “we don’t know why.”
Chasing the Rainbows provides free daily support and resources for families impacted by infertility, miscarriage, stillbirth, and infant loss.
👉 chasingtherainbows.org
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:10):
Crying Out Loud, a podcast by Chasing the Rainbows with your
host Bernice Quisenberry. Today's episode of Cried Out
Loud is one that so many in our community have been asking for a
(00:34):
deeper conversation around reoccurrent pregnancy loss,
infertility, and the medical questions families are often
left searching for answers on totheir own.
For parents who have experiencedmiscarriage after miscarriage,
loss after loss, the grief is devastating, but the uncertainty
can be just as painful. Questions like why did this
happen? Was it genetics, hormones, the
(00:55):
embryo, my body? Will this keep happening again?
Too often families are told it'sjust bad luck or just simply try
again. But recurrent pregnancy loss is
complex, and many parents are already doing deep dives trying
to understand the science behindwhat they've experienced.
That's why today we are joined by Doctor Ryan Martin, a board
(01:16):
certified reproductive endocrinologist and infertility
specialist with Shady Grove Fertility.
Doctor Martin earned his medicaldegree from Yale University
School of Medicine, completed his residency at Yale New Haven
Hospital, and went on to complete his fellowship and
reproductive endocrinology and infertility at Yale.
His work focuses on infertility,IVF, genetic screening, and
(01:39):
helping families navigate complex fertility challenge.
Beyond his medical expertise, Doctor Martin's story is one of
incredible perseverance after a tragic injury at age 12 left him
paralyzed from the waist down. He went on to become the very
first wheelchair bound graduate of Yale Medical School,
dedicating his life to helping others beyond their families.
(02:00):
Today we're going beyond surfacelevel conversations and diving
right into those real questions lost parents are asking about
genetics, embryos, sperm health,uterine factors, why early term
baby loss can still happen even when everything appears normal.
Doctor Martin, thank you for joining us and for helping our
listeners better understand the science behind recurrent
(02:21):
pregnancy loss while honoring the grief so many families
carry. Yeah, happy to happy to help.
Hopefully I can answer any questions that might help me get
through all this. Absolutely.
Well, thank you. And we'll dive right in because
we got a lot. We did hear you, listeners.
We appreciate your feedback, things that were submitted.
And yeah, we'll go right into it.
(02:42):
So medically recurrent pregnancyloss, RPL is often defined as
two or three consecutive miscarriages.
Do you believe we're waiting toolong before doing a full
evaluation, or should parents beoffered testing after two losses
instead of three? Well, the traditionally it was 3
(03:02):
losses. That's like the, the old
definition of it, like start to evaluate after three.
But most of us, including me, thought that was a little crazy
to say, well, after two losses, we're not going to check you.
Let's, let's then so, you know, wait for three, but we don't
really do that in, in, in practice nowadays.
(03:23):
We start to really check it after 2, you know, if you have
two in a row and you know, there's things that we can look
at and to start an evaluation and try and decrease the chance
of having a third. And we should definitely do
that. And so almost all my patients
really, it's that early that we see them.
And sometimes people come in at 2 and say, I don't know if I'm
(03:44):
here too early. And I say, no, you're here at
the perfect time. That's great, Ryan, just to be
able to go in to, you know, feelvalidated in their losses too,
because I know like 1 feels likea lot, you know, and then two
and it's, it's just, it is devastating.
So having a, you know, person who understands a provider to go
to and to turn to who? Tees it with.
(04:05):
Much care. Yeah, I mean, to come in and
say, well, we're really not going to do anything to give
another one is like a terrible thing to say and a terrible
thing to hear. Isn't it?
So we don't do that. Yes, I feel that so much.
Thank you. You know, we're often told a
miscarriage was due to a chromosomal abnormality or bad
luck. Can you explain the difference
(04:27):
between a random genetic error and something inherited like a
balanced translocation? And when should parents have
karyotype testing to check theirown chromosomes?
It's it's hard to hear unexplained.
A lot of times we don't get those answers, especially in the
early term losses. Yes, so, so this is a great
(04:48):
question. You know, I answered these types
of questions every day. And so one of the things that we
think about is all right, how dohow do we know that that
pregnancy losses are related to abnormal chromosomes?
We refer to that term as anuploidy, an embryo that is the
(05:08):
wrong number of chromosomes. We know that because when people
have DNCS or have surgery to take pregnancy tissue out, 2/3
to 3/4 of the time we find that there's a genetic abnormality.
Now, that can change based on a woman's age, but the general
idea is we see it often enough to know that that is a major
(05:30):
cause for losses. So what happens is they do some
genetic testing on the products of conception and lo and behold,
we find there's the wrong numberof chromosomes.
There are a couple ways that that happens.
One of the ways that we think that happens most often is
related to eggs. And a lot of that has to do with
biology, meaning women are born with all their eggs.
(05:52):
Men mix sperm all the time. So eggs used to get pregnant are
the age of the woman. Plus, you know, eggs were made
when they were 20 weeks in utero, right?
So if you were 36, the age of your eggs is probably 37.
And whereas sperm that is used to 'cause that pregnancy is
(06:14):
about 90 days old. So there's a lot more biologic
complexity to eggs than there iswith sperm.
And So what often happens is women ovulate an egg that
happens to be genetically abnormal.
Most of those eggs don't fertilize, but sometimes they do
(06:35):
and they do chromosomes. The embryo starts to implant
into the wall of the uterus, does the things that needs to
do, and then stops when it doesn't have the next
information to do the next thing, like throw a heartbeat or
whatever it is. And so that's the main etiology
for losses. From a genetic point of view,
sperm also play a role, and I think you'll probably ask me
some questions about it later, but sperm also plays a role in
(06:58):
aneuploidy as well. But in general, from a biologic
point of view that that is that's the case now, that is
someone with a normal genetic makeup, 2 parents with a normal
genetic makeup can have these aneuploid embryos.
It's a random event. Now, you asked a question about
(07:20):
whether or not there's a parental contribution to having
losses. And one of the genetic things
that we think about related to that is something called a
translocation. A translocation is something
that you can be born with that has no health implications and
shows up solely as recurrent losses.
And you can sort of think of it like our chromosomes are like an
(07:44):
encyclopedia, a set of encyclopedia books.
And we used to have those, and they're supposed to be an order,
and you're supposed to have the whole book, and they're supposed
to be an order. Now you could be born with an
abnormality in those in the order of those chromosomes or
whether or not you have a whole book or not.
(08:05):
And and that's called the translocation.
So pretend we're reading, reading a book and it's 10
chapters and chapter 10 and fiveare switched.
So we're reading chapter 1234 and then chapter 10.
So books now out of order, booksgoing great, but it's out of
order. We have the entire book.
(08:27):
So we have all the information we need, but it's out of order.
The same thing can happen with your chromosomes.
We refer to that as a translocation.
When I talk to my patients aboutthis translocation, it is an out
of order book. And basically what that means is
that if a woman has the the balance translocation, then you
(08:50):
can have more abnormal eggs. If the man has it, then you can
have more abnormal sperm. And so when they get together,
they make embryos that are abnormal and lead to losses.
And so part of our standard workup is to do karyotypes on both
parents to try and see if they have a translocation.
(09:14):
So as part of our standard loss work up, that's what we do.
So after 2-3 losses when someonecomes in to me, this is part of
the things that we look for because it's about 2% of the
time in recurrent losses that wesee something like this.
But it's a really bad thing to miss, so is there something we
can do about it? And so checking for that is
super important. I love how you Simply put that
(09:38):
with the chapters being out of order because it it makes so
much clearer sense, you know, then sometimes the medical way
of describing it. So thank you, Ryan for that.
Sure. Yeah, and you know what's
interesting? So yes, focus a lot on, you
know, eggs. I, you know, with my husband and
my secondary infertility journey, a lot of it was, you
(09:58):
know, me, it was me. And so, yeah, it, it's
interesting. So I, you know, never really had
to have the conversations aroundsperm health.
But, you know, with you mentioning that, how significant
is sperm, you know, DNA fragmentation and recurrent
pregnancy loss? And when should couples consider
advanced male factor testing? So this is a controversial
(10:22):
subject, and probably a reproductive urologist is going
to answer this in better ways than I can.
But the general idea is that we do know that sperm contributes
to recurrent pregnancy loss. And we know that for a fact that
I don't think there's any ambiguity about that.
But the question is, what do we do about it?
(10:43):
So the idea is, is that sperm can have DNA that's a little bit
fragmented or abnormal and that can happen as the sperm is in
the testes as opposed to part ofits how it was being generated.
So it has to do with like the storage, how long is it being
(11:05):
stored in creating this oxidative stress that leads to
fragmentation of the DNA. This then in turn could lead to
an abnormal sperm fertilizing anegg, making an abnormal embryo,
leading to aneuploidy. What we've been talking about
the wrong number of chromosomes.Now, in general, we don't really
(11:27):
test DNA fragmentation unless there's an abnormal sperm count
as a general rule. There are times where we can
certainly test DNA fragmentationand certainly can do it with
recurrent pregnancy loss, but it's not our part of our
standard testing because there'snot a lot of things we can do
about it. Meaning you can put somebody on
(11:52):
antioxidants, Coq 10, oxidative stress reducers, things like
that to try and help with that. If someone has like a structural
abnormality within the within the, the, the vasculature of the
testes, taking that out can certainly help if that's
(12:14):
contributing to DNA fragmentation.
There's some evidence that's very controversial that getting
sperm directly, surgically, directly from the testicle may
avoid some of the oxidative stress and and decrease DNA
fragmentation. That is a very controversial
(12:34):
thing that you'll see reproductive urologist lean
towards or lean away over time, but there's not a lot of things
to do to fix it. And so the question is like, how
much do you want to check those things when there's not much you
can do about it? Right.
At least you know getting pregnant on your own.
(12:54):
Right. Wow.
Thanks for explaining that. Yeah.
And yeah, that's really interesting actually, and that
doctors fall either way with it.Yeah, as more evidence comes out
and, you know, in reproductive medicine, it's really
complicated to get some great answers that really isolate the
(13:17):
problem that you're looking at. So some studies will like kind
of lean in One Direction, otherswill not.
And so that when you get like a full evaluation, you take a full
picture of things, you don't seeit necessarily definitive in one
way or the other. And that's why people start to
kind of waffle between how can Ireally help somebody or not.
(13:38):
Yeah, and sometimes it, I mean not to speak or anything running
out of turn, but almost trial and error with some of these
things too is what it almost feels like.
And some treatments are more effective for specific
individuals than others. And we just don't change no
more. Yeah, trying to figure out what
works best. Yeah, woof.
(14:00):
So with families who go through IVF with pre implantation
genetic testing, miscarriages still occur.
You know, can you explain mosaicembryos, the limitations of
embryo testing, and why a genetically normal embryo
doesn't always guarantee a live birth?
Yeah. So as I was saying to you, one
(14:25):
of the leading cause of losses is related to an embryo that's
abnormal. But there's many other factors
that can be involved with lossesand so we can't control all the
things from an embryo point of view.
Testing of the embryos is one way that we can try and reduce
miscarriages by avoiding transferring an embryo that has
(14:48):
the wrong number of chromosomes.It's called pre genetic testing
of the embryos and specifically we take a few cells off the
outside of an embryo and then freeze the embryo.
The cells that we take off we send to a lab.
That lab will then tell us how many chromosomes does each
embryo have from a So from a selection of an embryo point of
(15:11):
view, it's very helpful because I can then say to you that
embryo with the wrong number of chromosomes is not going to lead
to a live birth or it's going tolead to a miscarriage.
Whereas these other ones that are that have the right number
of chromosomes are far, far morelikely to yield a healthy
pregnancy. So pre genetic testing in the
(15:35):
embryos is helpful in that way to decrease the chance that you
would have a loss due to amuplity, which is a big reason
for losses. So I can reduce that, but I
can't really reduce the chance. We have losses due to other
factors that are either unknown or uncontrollable to us.
So I think each lab is different.
(15:58):
But I think, you know, in our lab probably we can get
miscarriage rates down to about 13 percent or so when we
transfer euploid embryo. So we can get it down, but we
can't get it down all the way because there's a million other
things that we don't know is theI don't know category that kind
(16:20):
of that can contribute. So the idea when people come to
see me with recurrent losses andthey want to do IVF and test
their embryos, it's a good startto really decrease the chance of
a loss due to the wrong number of chromosomes.
But there's other factors that Ican't control and I'm super
transparent about that with people because I just, I want
(16:40):
you to know what we can control,what we can't.
Some of this is random that I don't have control over and the
patient doesn't have control over, and so some of that is
that lost feeling, like I can't control all of it.
But it's important to just transparently know that.
Really it is. And especially, you know, with
someone who's gone through loss after loss, having a, a care
(17:03):
team, a provider who is saying to you, listen, this is what we
can control. This is what we can't.
I'm going to be clearly transparent with you, but also
I'm going to be honest and very upfront.
And that's really like what we're looking for because, you
know, with trauma, we're alreadyfeeling like isolated shut down.
Who do we trust? You know, who's our safe space?
(17:25):
And when we have those open commutative, you know,
conversations with that, whoever's treating us, we feel
like we can almost break down those barriers more.
And we know going into this a lot more than we would if we
didn't have those conversations.It's so important.
Yeah. I mean, I, I sort of, you know,
this is like one of the mainstays of how, you know, we
(17:46):
communicate with people is to say, look, these are the things
to expect when we get our testing done, when we go over
the testing, These are the things that I'm going to talk to
you about. These are some of the things
that I know and just don't know,but I'll be super transparent
and we'll discuss it all together.
I think that just kind of allowsyou to absorb the information in
a more informative way. Absolutely.
(18:09):
I know we can't preach that enough around here.
So thank you, Ryan, for that. Yeah.
You know, how often are uterine abnormalities like a septum,
scar tissue or fibroids overlooked on routine
ultrasounds? When someone you know requests
more advanced imaging, when should they do that?
(18:30):
Like a saline sonogram or MRI? So it is part of our standard to
evaluate the structure of the uterus both with fertility, I do
that with infertility patients, but also with recurrent loss
patients. There are some conditions that
we think are associated with losses, specifically septums for
(18:51):
sure. But there are other conditions
with abnormal development of an,of, of a uterus or things that
can change over time like fibroids, polyps, endometriosis,
adenomyosis, things like that, that can affect things.
But so a salient sonogram is absolutely the first thing that
(19:14):
I do. And I'm wanting to know, is
there anything about the structure of the uterus that's
that that's contributing to this?
Now, if someone has a septum, we're actually kind of cheering
because it's like, great, I could take care of that in 10
minutes. I can do a hysteroscopy and even
out that septum and return your chances back to normal in terms
(19:37):
of losses just with that. So when someone has that great
news, I always kind of go back to the story when when I was
first out of fellowship and I was practicing and I saw a
patient who had had a child before but then had a bunch of
losses as well. And she had a child, had AC
(20:00):
section losses in a row. Came to see me and said, and I
told them about the recurrent loss work up and part of it was
the saline sonogram to look at the lining of the uterus.
She said I've had losses. I've had all these ultrasounds
with my losses. I had AC section, they had my
uterus out. They were cleaning out the
placenta. Like people have looked at my
uterus, I'm sure it's fine. I said, well, let's check it
(20:24):
out. And she had a big septum.
So it had been missed on many ultrasounds with the losses it
had missed been missed on the C-section.
And so we fixed, you know, I fixed her septum and then she
went on to have a kid. And it's just like one of those
things that I remember early on as a, as a doc saying, you know,
(20:46):
remember this one because these are things that are probably not
the most common, but it's sort of clarifies the reason for, for
looking. And so we look.
And looking out of a different lens right too.
So for example, have had fibroids and cysts removed over
(21:07):
the years. You know, the doctors were
really focused on removing those, not necessarily what it
was causing with fertility or anything like that, right?
Because that was their main focus when I was, you know,
getting treated for those thingsand then, you know, needing
corrective surgeries and things like that.
It's, it's almost like, you know, because then when we were
trying to get pregnant and couldn't, our doctor was looking
(21:28):
at it from a different way, an angle and everything.
And it is really interesting you're saying this, Ryan,
because it, I really think and then, you know, looking at lab
work is kind of the same way where if you're looking at it,
is this person surviving or are they thriving for getting
pregnant? It's a whole different way
you're looking at things. Yeah, and it kind of makes me
think of like when people come to talk to me about PCOS, right,
(21:52):
And elevated male hormones, for example, I've got dark hairs
that are growing that I that, that I have the polar plaque,
right? I've got some acne, but my
testosterone levels are normal. So I don't have PCOS.
Well, that's not the that's not the situation.
You might have testosterone levels that are on the scale
(22:13):
normal but not normal for you. And so you have to kind of take
all this stuff with a grain of salt, which is and directed more
to the individual patient to say, wait, look at all these
things, this is the right pattern.
Even if their blood tests are normal, that doesn't mean it's
normal for them. So it just kind of reminds me of
that thought. Yes, absolutely.
(22:34):
That individualized approach, yeah.
Oh, Ryan. Yeah.
And endometriosis, it's, you know, the silent inflammation
isn't just about pain, but the inflammatory piece of it.
How can that chronic inflammation affect implantation
or early pregnancy even when ovulation and fertilization are
(22:58):
happening, especially with the reoccurring losses?
Well, you know, what we know is that there are some inflammatory
conditions that can lead to difficulty getting pregnant and
staying pregnant. Endometriosis is a very common
thing for us to be aware of, butalso a very difficult thing to
diagnose. Part of the reason for that is
(23:21):
the only way you can truly diagnose endometriosis is to do
a laparoscopy. So you do a surgery, you look
for the condition, you take a biopsy of it, and you give it to
the pathologist. They look under a microscope and
say yes, that's endo. But it's really not a good way
(23:41):
to do this. In other words, why would you
take the risk of a laparoscopy when you don't need to?
So in general most reproductive endocrinologist will advocate
not having a surgery and to justbe aware that endometriosis may
be playing a role in this, especially if someone has
painful periods. But the reality is, is that over
(24:06):
the years, reproductive endocrinologists have gone from
doing a laparoscopy on many people to look at tubes and
endometriosis to saying, why am I exposing people to risk with
this surgery when I can just getthrough treatments that are very
successful to work whether or not you had a laparoscopy or
not. So the general idea is we tend
(24:28):
to do laparoscopies only if someone has such severe pain
that it warrants the surgery. You don't do it specifically for
fertility. And there's one old study that
said that you would need to do 37 laparoscopies on people to
have one additional pregnancy. So basically it was saying doing
(24:49):
these surgeries are not helpful from a fertility perspective.
Now if you have a lot of pain with your parents and it
warrants a surgery and endometriosis taken back, you
may get some fertility benefit from it.
But the reality is we tend not to do that.
But in general, endometriosis and its cousin adenomyosis,
(25:12):
which is in the endometriosis that's in the wall of the
uterus, those are things that are basically hyper inflammatory
conditions that can lead to difficulty implanting.
And there's different ways that we handle adenomyosis and
endometriosis depending on what kind of treatments people are
are involved in. But it definitely effects
(25:34):
implantation. It can make, even if you do
implant, for example, with adenomyosis, it can make the
placenta less effective at finding the bloodstream, which
can, which can compromise the growth of the baby over time.
So there are longitudinal problems that can happen during
a during a pregnancy, not just getting pregnant itself, but
(25:58):
trying to get through the pregnancy.
So those are all things that we consider when we're taking care
of people with these conditions.Wow.
Wow. Yeah.
And this, I mean, just to go into, you know, after loss too,
and, and hormones and things like that.
Many women, myself included, were prescribed progesterone
(26:21):
after loss. How common is that in the, you
know, to supplement that and meaningfully to improve
pregnancy outcomes? So the way that I talk about
this with my patients is to say,do I give progesterone in the
(26:41):
second-half the cycle when people are doing any sort of
treatment here? And the answer is yes.
But the reason I do it is not because I know it works, but
because there's not a lot of downside.
So people come to me and say my cousin had trouble getting
pregnant. They were given progesterone and
I had a baby and they had a baby, you know, And so there's a
(27:03):
lot of these associations that people have.
But what people don't realize isthat if someone has their
progesterone checked and it's low, we don't truly know if it's
low because progesterone is secreted in a, what they call a
pulsatile way. So, so if you checked it over
and over again over 10 hours, you get a wildly different
(27:25):
numbers. So seeing a low number is not
necessarily meaning that you've got a low progesterone level.
And if you truly did have a low progesterone level, it's likely
because the pregnancy was abnormal, not because you just
have a, you're not producing progesterone.
So I can give you progesterone, which fixes the progesterone
(27:46):
level, but doesn't fix an abnormal pregnancy.
So while we give it, I talk to my patients and say, look,
transparently, I don't know if this is helping, but there's not
a downside. If you were one of the very rare
people who had an issue with making progesterone, here it is.
But not to say that giving progesterone fixes an abnormal
(28:10):
pregnancy. So it's a little controversial.
Some people shy away from givingit.
I don't think there's really a downside to doing it.
So we often will give it to people.
But with the transparent angle to say, I don't know how much
I'm helping, but I'm not hurting, let's cover that as a
possibility. And so that's the, that's the
(28:34):
way I typically talk about it, yeah.
No, and I think that's great to understand, right, because even
thinking back when I, you know, was on it, they had there wasn't
really any risks or long term effects or anything like that
that, you know, and I'm gratefulto hear that it's still like
that, you know, Brian. Yeah.
The only thing that you have to be aware of is theoretically it
(28:55):
could delay a pregnancy, sorry, a bleed if you weren't pregnant.
Theoretically, when I see patients, they're coming to see
me for a pregnancy test. Yeah.
Specific time and so if their pregnancy test is negative, we
stop the medications. But if you're doing that on your
own, you could delay your pregnancy, your bleed after
(29:17):
negative pregnancy test a littlebit with it.
But I encourage people to just take the pregnancy test at home
if that's what you're doing. And if it's negative, stop it.
Yeah, most of the times we are. We're testing everything at.
Home too. Right.
Yeah. And you know, for the IVF like
(29:37):
reducing risks with miscarriage,you know, when we're having
reoccurring pregnancy losses, when does IVF with genetic
testing statistically reduce that risk and when might it not
significantly improve outcomes compared to natural conception?
Well, what I would say to you isI think the, the, the real
(29:58):
statement is to say it's a faster time to a successful
pregnancy. So it doesn't necessarily
increase the pregnancy rates, but the testing of the embryos.
But it does allow us to select an embryo that has the
capability of a live birth faster than if we didn't do
(30:21):
testing. So for example, if we had five
embryos to work with and they were not tested and two were
abnormal and three were normal, I am transferring an embryo one
at a time based on how the embryos look, the more the
grating and whether that embryo is normal or not is kind of
(30:43):
random. It's not necessarily related to
the grading. So I'm a one in five chance of
transferring it, you know, or two in five chance of having an
embryo that transferring an embryo that is the wrong number
of chromosomes, that is not going to work.
So I would say to you it's a faster time to a successful
pregnancy because I can select an embryo that has a or deselect
(31:07):
an embryo that. Cannot be right.
Yeah. Well and it's going into a very
evidence based, you know, based on seeing what you're able to
test with the embryos and everything ahead of time.
And with this testing, really all we're testing is the number
of chromosomes. I can't tell every little single
thing about an embryo. The way to the way to kind of
(31:29):
think about it is back-to-back to the encyclopedias that I can
tell if you have the right number of books in the
encyclopedia set. But I can't tell you in book 3
that chapter 2 is written backwards, right?
I can't tell little details, butI could tell the main building
(31:50):
blocks to say, look, this has the right number.
Once the don't have the right number or embryos that we should
have put, Yeah. That's good to know.
Thanks for clarifying that, Ryan.
And down to our last one and this is a big one.
I know that I saved this for last and we already were talking
about eggs a little bit, but this is what our community, you
know, we always feel like our eggs are on timers.
(32:12):
And I know we touched on it a little bit.
You know, when looking at if we're 36, it's really 37 for our
eggs because we're born with allof them.
You know, we hear about age and egg quality.
Are there biomarkers beyond AMH that better predict miscarriage
risk? And how do you counsel patients
without oversimplifying fertility decline?
(32:36):
I know it's a Josie. Well, I think what we, what I go
back to when I talk to patients is biology and I, I go through
the whole thing with all your eggs.
So over time there are, there are chances for eggs to become
abnormal over time. And remember, our parents
generation tended to have kids at younger ages, right?
(32:58):
And so maybe there was less of the age factor involved, whereas
our generation is a little different and people having
babies later in life, which now introduces more egg quality
issues over time. So the general idea is I can't
rate someone's quality of eggs. I can't say your eggs are an 8
(33:22):
out of 10. But I can say, look, your
birthday is what dictates the likelihood of having more good
eggs than bad eggs. And one of the ways that we know
all this information is not justthe fact that miscarriage rates
go up over over a woman's age. That's evidence that we have
(33:48):
abnormal embryos or abnormal eggs leading to abnormal
embryos. But the other is when we test
embryos to see if they're genetically normal, we have
certain expectations about pregnancy.
Sorry, Aneuploid rates the rate of an abnormal embryo based on
the woman's age. So at the age of 30, about 75%
(34:12):
of beautiful blastocyst embryos are normal.
At the age of 40, about 75% are genetically abnormal even though
they look fantastic. And 35 to 36 is where you have
that 50. So if a woman has 6 embryos and
(34:33):
she's 35, I'm going to say maybewe've got 3 normals in here.
If a woman's 40, we're starting to say a lot less.
And so, so I think it's important to talk about some of
that biology and some of the expectations.
But when people talk about AMHS,I love AMHS.
(34:53):
It's a great way of understanding your egg reserve
over time. It's a hormone that is made by
the cells that are around your eggs.
So the more eggs you have, the more cells around the eggs, the
higher the number. So AMH is a fantastic way to try
and get a feel for your quantity, but it doesn't say
(35:13):
that there's a problem with quality.
So if someone has a low AMH and they're coming to see me, I am
saying to you, you have a low amount of eggs.
I don't know that you have bad eggs in any way, shape or form.
If someone is 40, I'm worried about their eggs.
If someone's 30, I'm worried about them less.
AMH is really more so to say what's my reproductive longevity
(35:37):
as opposed to my quality. So I think understanding that if
you get a test, kind of understanding what it's telling
you is super important. So AMH is more related to your
quantity. AMH does not tell us if it's low
that you're not going to get pregnant.
Wow. I don't know if I answered your
(35:58):
question, but that. Yes, yes, you did, you did
absolutely. Thank you and thank you for
answering all these, you know, questions.
A lot of survivors in our community go through reoccurring
loss. So, you know, and, and when this
happens, it's always nice when we can give them an expert who
can answer some questions for them that they don't feel
(36:19):
comfortable asking or they're not ready to ask themselves.
So they give it to us. So we just can't thank you
enough for that, Ryan. And I would love for you to
leave our listeners with words of advice or any you know little
ending that you would like to. I would say to you, if you feel
(36:39):
like you're having trouble to reach out to somebody, certainly
with reproductive endocrinology,there are some aspects that we
don't have answers to. But many times we do have some
answers and we can certainly talk you through them.
And whether or not you do something about it is a
different story. But if you want to get some
(37:00):
answers, there are things that we can do to help you avoid
either difficulty getting pregnant or recurrent losses.
There's some treatments that arequite effective.
There are other situations wherethey're not, but the testing and
confiding in somebody is probably the first step.
(37:23):
Thank you. Thank you for leaving our
listeners with that. Sure.
And thank you so much for joining us today for sharing
your expertise, your perspective, and a deeper
medical understanding beyond, you know, reoccurring pregnancy
loss. Conversations like this matter
because they help families feel less alone and remind them that
their questions, their grief, and their search for answers are
(37:43):
valid. So thank you, Ryan.
Yeah, happy to help. Thank you to anyone listening
who might be navigating infertility, reoccurrent
pregnancy loss, miscarriage, still birth, any type of
pregnancy, or infant loss. Please know your story matters,
your baby matters, and your grief matters.
Healing doesn't follow a timeline.
Trauma and loss don't have a schedule, and you deserve
(38:04):
compassionate support through every step of your journey.
At Chasing the Rainbows, we provide daily support services,
free and community for families impacted by infertility,
pregnancy, and info loss. Because every loss matters.
If this conversation resonates with you, please share this
episode with someone who may need it.
And if you are looking for support, want to
(38:24):
volunteerdonateorhostaneventinhonorofyourbabyyoucanlearnmore@chasingtherainbows.org.Thank you for being here, for
listening, and for continuing tobreak the silence around
infertility and baby loss. Until next time this is cried
out loud, thank you.
Crying Out Loud, a podcast by Chasing the Rainbows with your
host Bernice Quisenberry. Today's episode of Cried Out
Loud is one that so many in our community have been asking for a
(00:34):
deeper conversation around reoccurrent pregnancy loss,
infertility, and the medical questions families are often
left searching for answers on totheir own.
For parents who have experiencedmiscarriage after miscarriage,
loss after loss, the grief is devastating, but the uncertainty
can be just as painful. Questions like why did this
happen? Was it genetics, hormones, the
(00:55):
embryo, my body? Will this keep happening again?
Too often families are told it'sjust bad luck or just simply try
again. But recurrent pregnancy loss is
complex, and many parents are already doing deep dives trying
to understand the science behindwhat they've experienced.
That's why today we are joined by Doctor Ryan Martin, a board
(01:16):
certified reproductive endocrinologist and infertility
specialist with Shady Grove Fertility.
Doctor Martin earned his medicaldegree from Yale University
School of Medicine, completed his residency at Yale New Haven
Hospital, and went on to complete his fellowship and
reproductive endocrinology and infertility at Yale.
His work focuses on infertility,IVF, genetic screening, and
(01:39):
helping families navigate complex fertility challenge.
Beyond his medical expertise, Doctor Martin's story is one of
incredible perseverance after a tragic injury at age 12 left him
paralyzed from the waist down. He went on to become the very
first wheelchair bound graduate of Yale Medical School,
dedicating his life to helping others beyond their families.
(02:00):
Today we're going beyond surfacelevel conversations and diving
right into those real questions lost parents are asking about
genetics, embryos, sperm health,uterine factors, why early term
baby loss can still happen even when everything appears normal.
Doctor Martin, thank you for joining us and for helping our
listeners better understand the science behind recurrent
(02:21):
pregnancy loss while honoring the grief so many families
carry. Yeah, happy to happy to help.
Hopefully I can answer any questions that might help me get
through all this. Absolutely.
Well, thank you. And we'll dive right in because
we got a lot. We did hear you, listeners.
We appreciate your feedback, things that were submitted.
And yeah, we'll go right into it.
(02:42):
So medically recurrent pregnancyloss, RPL is often defined as
two or three consecutive miscarriages.
Do you believe we're waiting toolong before doing a full
evaluation, or should parents beoffered testing after two losses
instead of three? Well, the traditionally it was 3
(03:02):
losses. That's like the, the old
definition of it, like start to evaluate after three.
But most of us, including me, thought that was a little crazy
to say, well, after two losses, we're not going to check you.
Let's, let's then so, you know, wait for three, but we don't
really do that in, in, in practice nowadays.
(03:23):
We start to really check it after 2, you know, if you have
two in a row and you know, there's things that we can look
at and to start an evaluation and try and decrease the chance
of having a third. And we should definitely do
that. And so almost all my patients
really, it's that early that we see them.
And sometimes people come in at 2 and say, I don't know if I'm
(03:44):
here too early. And I say, no, you're here at
the perfect time. That's great, Ryan, just to be
able to go in to, you know, feelvalidated in their losses too,
because I know like 1 feels likea lot, you know, and then two
and it's, it's just, it is devastating.
So having a, you know, person who understands a provider to go
to and to turn to who? Tees it with.
(04:05):
Much care. Yeah, I mean, to come in and
say, well, we're really not going to do anything to give
another one is like a terrible thing to say and a terrible
thing to hear. Isn't it?
So we don't do that. Yes, I feel that so much.
Thank you. You know, we're often told a
miscarriage was due to a chromosomal abnormality or bad
luck. Can you explain the difference
(04:27):
between a random genetic error and something inherited like a
balanced translocation? And when should parents have
karyotype testing to check theirown chromosomes?
It's it's hard to hear unexplained.
A lot of times we don't get those answers, especially in the
early term losses. Yes, so, so this is a great
(04:48):
question. You know, I answered these types
of questions every day. And so one of the things that we
think about is all right, how dohow do we know that that
pregnancy losses are related to abnormal chromosomes?
We refer to that term as anuploidy, an embryo that is the
(05:08):
wrong number of chromosomes. We know that because when people
have DNCS or have surgery to take pregnancy tissue out, 2/3
to 3/4 of the time we find that there's a genetic abnormality.
Now, that can change based on a woman's age, but the general
idea is we see it often enough to know that that is a major
(05:30):
cause for losses. So what happens is they do some
genetic testing on the products of conception and lo and behold,
we find there's the wrong numberof chromosomes.
There are a couple ways that that happens.
One of the ways that we think that happens most often is
related to eggs. And a lot of that has to do with
biology, meaning women are born with all their eggs.
(05:52):
Men mix sperm all the time. So eggs used to get pregnant are
the age of the woman. Plus, you know, eggs were made
when they were 20 weeks in utero, right?
So if you were 36, the age of your eggs is probably 37.
And whereas sperm that is used to 'cause that pregnancy is
(06:14):
about 90 days old. So there's a lot more biologic
complexity to eggs than there iswith sperm.
And So what often happens is women ovulate an egg that
happens to be genetically abnormal.
Most of those eggs don't fertilize, but sometimes they do
(06:35):
and they do chromosomes. The embryo starts to implant
into the wall of the uterus, does the things that needs to
do, and then stops when it doesn't have the next
information to do the next thing, like throw a heartbeat or
whatever it is. And so that's the main etiology
for losses. From a genetic point of view,
sperm also play a role, and I think you'll probably ask me
some questions about it later, but sperm also plays a role in
(06:58):
aneuploidy as well. But in general, from a biologic
point of view that that is that's the case now, that is
someone with a normal genetic makeup, 2 parents with a normal
genetic makeup can have these aneuploid embryos.
It's a random event. Now, you asked a question about
(07:20):
whether or not there's a parental contribution to having
losses. And one of the genetic things
that we think about related to that is something called a
translocation. A translocation is something
that you can be born with that has no health implications and
shows up solely as recurrent losses.
And you can sort of think of it like our chromosomes are like an
(07:44):
encyclopedia, a set of encyclopedia books.
And we used to have those, and they're supposed to be an order,
and you're supposed to have the whole book, and they're supposed
to be an order. Now you could be born with an
abnormality in those in the order of those chromosomes or
whether or not you have a whole book or not.
(08:05):
And and that's called the translocation.
So pretend we're reading, reading a book and it's 10
chapters and chapter 10 and fiveare switched.
So we're reading chapter 1234 and then chapter 10.
So books now out of order, booksgoing great, but it's out of
order. We have the entire book.
(08:27):
So we have all the information we need, but it's out of order.
The same thing can happen with your chromosomes.
We refer to that as a translocation.
When I talk to my patients aboutthis translocation, it is an out
of order book. And basically what that means is
that if a woman has the the balance translocation, then you
(08:50):
can have more abnormal eggs. If the man has it, then you can
have more abnormal sperm. And so when they get together,
they make embryos that are abnormal and lead to losses.
And so part of our standard workup is to do karyotypes on both
parents to try and see if they have a translocation.
(09:14):
So as part of our standard loss work up, that's what we do.
So after 2-3 losses when someonecomes in to me, this is part of
the things that we look for because it's about 2% of the
time in recurrent losses that wesee something like this.
But it's a really bad thing to miss, so is there something we
can do about it? And so checking for that is
super important. I love how you Simply put that
(09:38):
with the chapters being out of order because it it makes so
much clearer sense, you know, then sometimes the medical way
of describing it. So thank you, Ryan for that.
Sure. Yeah, and you know what's
interesting? So yes, focus a lot on, you
know, eggs. I, you know, with my husband and
my secondary infertility journey, a lot of it was, you
(09:58):
know, me, it was me. And so, yeah, it, it's
interesting. So I, you know, never really had
to have the conversations aroundsperm health.
But, you know, with you mentioning that, how significant
is sperm, you know, DNA fragmentation and recurrent
pregnancy loss? And when should couples consider
advanced male factor testing? So this is a controversial
(10:22):
subject, and probably a reproductive urologist is going
to answer this in better ways than I can.
But the general idea is that we do know that sperm contributes
to recurrent pregnancy loss. And we know that for a fact that
I don't think there's any ambiguity about that.
But the question is, what do we do about it?
(10:43):
So the idea is, is that sperm can have DNA that's a little bit
fragmented or abnormal and that can happen as the sperm is in
the testes as opposed to part ofits how it was being generated.
So it has to do with like the storage, how long is it being
(11:05):
stored in creating this oxidative stress that leads to
fragmentation of the DNA. This then in turn could lead to
an abnormal sperm fertilizing anegg, making an abnormal embryo,
leading to aneuploidy. What we've been talking about
the wrong number of chromosomes.Now, in general, we don't really
(11:27):
test DNA fragmentation unless there's an abnormal sperm count
as a general rule. There are times where we can
certainly test DNA fragmentationand certainly can do it with
recurrent pregnancy loss, but it's not our part of our
standard testing because there'snot a lot of things we can do
about it. Meaning you can put somebody on
(11:52):
antioxidants, Coq 10, oxidative stress reducers, things like
that to try and help with that. If someone has like a structural
abnormality within the within the, the, the vasculature of the
testes, taking that out can certainly help if that's
(12:14):
contributing to DNA fragmentation.
There's some evidence that's very controversial that getting
sperm directly, surgically, directly from the testicle may
avoid some of the oxidative stress and and decrease DNA
fragmentation. That is a very controversial
(12:34):
thing that you'll see reproductive urologist lean
towards or lean away over time, but there's not a lot of things
to do to fix it. And so the question is like, how
much do you want to check those things when there's not much you
can do about it? Right.
At least you know getting pregnant on your own.
(12:54):
Right. Wow.
Thanks for explaining that. Yeah.
And yeah, that's really interesting actually, and that
doctors fall either way with it.Yeah, as more evidence comes out
and, you know, in reproductive medicine, it's really
complicated to get some great answers that really isolate the
(13:17):
problem that you're looking at. So some studies will like kind
of lean in One Direction, otherswill not.
And so that when you get like a full evaluation, you take a full
picture of things, you don't seeit necessarily definitive in one
way or the other. And that's why people start to
kind of waffle between how can Ireally help somebody or not.
(13:38):
Yeah, and sometimes it, I mean not to speak or anything running
out of turn, but almost trial and error with some of these
things too is what it almost feels like.
And some treatments are more effective for specific
individuals than others. And we just don't change no
more. Yeah, trying to figure out what
works best. Yeah, woof.
(14:00):
So with families who go through IVF with pre implantation
genetic testing, miscarriages still occur.
You know, can you explain mosaicembryos, the limitations of
embryo testing, and why a genetically normal embryo
doesn't always guarantee a live birth?
Yeah. So as I was saying to you, one
(14:25):
of the leading cause of losses is related to an embryo that's
abnormal. But there's many other factors
that can be involved with lossesand so we can't control all the
things from an embryo point of view.
Testing of the embryos is one way that we can try and reduce
miscarriages by avoiding transferring an embryo that has
(14:48):
the wrong number of chromosomes.It's called pre genetic testing
of the embryos and specifically we take a few cells off the
outside of an embryo and then freeze the embryo.
The cells that we take off we send to a lab.
That lab will then tell us how many chromosomes does each
embryo have from a So from a selection of an embryo point of
(15:11):
view, it's very helpful because I can then say to you that
embryo with the wrong number of chromosomes is not going to lead
to a live birth or it's going tolead to a miscarriage.
Whereas these other ones that are that have the right number
of chromosomes are far, far morelikely to yield a healthy
pregnancy. So pre genetic testing in the
(15:35):
embryos is helpful in that way to decrease the chance that you
would have a loss due to amuplity, which is a big reason
for losses. So I can reduce that, but I
can't really reduce the chance. We have losses due to other
factors that are either unknown or uncontrollable to us.
So I think each lab is different.
(15:58):
But I think, you know, in our lab probably we can get
miscarriage rates down to about 13 percent or so when we
transfer euploid embryo. So we can get it down, but we
can't get it down all the way because there's a million other
things that we don't know is theI don't know category that kind
(16:20):
of that can contribute. So the idea when people come to
see me with recurrent losses andthey want to do IVF and test
their embryos, it's a good startto really decrease the chance of
a loss due to the wrong number of chromosomes.
But there's other factors that Ican't control and I'm super
transparent about that with people because I just, I want
(16:40):
you to know what we can control,what we can't.
Some of this is random that I don't have control over and the
patient doesn't have control over, and so some of that is
that lost feeling, like I can't control all of it.
But it's important to just transparently know that.
Really it is. And especially, you know, with
someone who's gone through loss after loss, having a, a care
(17:03):
team, a provider who is saying to you, listen, this is what we
can control. This is what we can't.
I'm going to be clearly transparent with you, but also
I'm going to be honest and very upfront.
And that's really like what we're looking for because, you
know, with trauma, we're alreadyfeeling like isolated shut down.
Who do we trust? You know, who's our safe space?
(17:25):
And when we have those open commutative, you know,
conversations with that, whoever's treating us, we feel
like we can almost break down those barriers more.
And we know going into this a lot more than we would if we
didn't have those conversations.It's so important.
Yeah. I mean, I, I sort of, you know,
this is like one of the mainstays of how, you know, we
(17:46):
communicate with people is to say, look, these are the things
to expect when we get our testing done, when we go over
the testing, These are the things that I'm going to talk to
you about. These are some of the things
that I know and just don't know,but I'll be super transparent
and we'll discuss it all together.
I think that just kind of allowsyou to absorb the information in
a more informative way. Absolutely.
(18:09):
I know we can't preach that enough around here.
So thank you, Ryan, for that. Yeah.
You know, how often are uterine abnormalities like a septum,
scar tissue or fibroids overlooked on routine
ultrasounds? When someone you know requests
more advanced imaging, when should they do that?
(18:30):
Like a saline sonogram or MRI? So it is part of our standard to
evaluate the structure of the uterus both with fertility, I do
that with infertility patients, but also with recurrent loss
patients. There are some conditions that
we think are associated with losses, specifically septums for
(18:51):
sure. But there are other conditions
with abnormal development of an,of, of a uterus or things that
can change over time like fibroids, polyps, endometriosis,
adenomyosis, things like that, that can affect things.
But so a salient sonogram is absolutely the first thing that
(19:14):
I do. And I'm wanting to know, is
there anything about the structure of the uterus that's
that that's contributing to this?
Now, if someone has a septum, we're actually kind of cheering
because it's like, great, I could take care of that in 10
minutes. I can do a hysteroscopy and even
out that septum and return your chances back to normal in terms
(19:37):
of losses just with that. So when someone has that great
news, I always kind of go back to the story when when I was
first out of fellowship and I was practicing and I saw a
patient who had had a child before but then had a bunch of
losses as well. And she had a child, had AC
(20:00):
section losses in a row. Came to see me and said, and I
told them about the recurrent loss work up and part of it was
the saline sonogram to look at the lining of the uterus.
She said I've had losses. I've had all these ultrasounds
with my losses. I had AC section, they had my
uterus out. They were cleaning out the
placenta. Like people have looked at my
uterus, I'm sure it's fine. I said, well, let's check it
(20:24):
out. And she had a big septum.
So it had been missed on many ultrasounds with the losses it
had missed been missed on the C-section.
And so we fixed, you know, I fixed her septum and then she
went on to have a kid. And it's just like one of those
things that I remember early on as a, as a doc saying, you know,
(20:46):
remember this one because these are things that are probably not
the most common, but it's sort of clarifies the reason for, for
looking. And so we look.
And looking out of a different lens right too.
So for example, have had fibroids and cysts removed over
(21:07):
the years. You know, the doctors were
really focused on removing those, not necessarily what it
was causing with fertility or anything like that, right?
Because that was their main focus when I was, you know,
getting treated for those thingsand then, you know, needing
corrective surgeries and things like that.
It's, it's almost like, you know, because then when we were
trying to get pregnant and couldn't, our doctor was looking
(21:28):
at it from a different way, an angle and everything.
And it is really interesting you're saying this, Ryan,
because it, I really think and then, you know, looking at lab
work is kind of the same way where if you're looking at it,
is this person surviving or are they thriving for getting
pregnant? It's a whole different way
you're looking at things. Yeah, and it kind of makes me
think of like when people come to talk to me about PCOS, right,
(21:52):
And elevated male hormones, for example, I've got dark hairs
that are growing that I that, that I have the polar plaque,
right? I've got some acne, but my
testosterone levels are normal. So I don't have PCOS.
Well, that's not the that's not the situation.
You might have testosterone levels that are on the scale
(22:13):
normal but not normal for you. And so you have to kind of take
all this stuff with a grain of salt, which is and directed more
to the individual patient to say, wait, look at all these
things, this is the right pattern.
Even if their blood tests are normal, that doesn't mean it's
normal for them. So it just kind of reminds me of
that thought. Yes, absolutely.
(22:34):
That individualized approach, yeah.
Oh, Ryan. Yeah.
And endometriosis, it's, you know, the silent inflammation
isn't just about pain, but the inflammatory piece of it.
How can that chronic inflammation affect implantation
or early pregnancy even when ovulation and fertilization are
(22:58):
happening, especially with the reoccurring losses?
Well, you know, what we know is that there are some inflammatory
conditions that can lead to difficulty getting pregnant and
staying pregnant. Endometriosis is a very common
thing for us to be aware of, butalso a very difficult thing to
diagnose. Part of the reason for that is
(23:21):
the only way you can truly diagnose endometriosis is to do
a laparoscopy. So you do a surgery, you look
for the condition, you take a biopsy of it, and you give it to
the pathologist. They look under a microscope and
say yes, that's endo. But it's really not a good way
(23:41):
to do this. In other words, why would you
take the risk of a laparoscopy when you don't need to?
So in general most reproductive endocrinologist will advocate
not having a surgery and to justbe aware that endometriosis may
be playing a role in this, especially if someone has
painful periods. But the reality is, is that over
(24:06):
the years, reproductive endocrinologists have gone from
doing a laparoscopy on many people to look at tubes and
endometriosis to saying, why am I exposing people to risk with
this surgery when I can just getthrough treatments that are very
successful to work whether or not you had a laparoscopy or
not. So the general idea is we tend
(24:28):
to do laparoscopies only if someone has such severe pain
that it warrants the surgery. You don't do it specifically for
fertility. And there's one old study that
said that you would need to do 37 laparoscopies on people to
have one additional pregnancy. So basically it was saying doing
(24:49):
these surgeries are not helpful from a fertility perspective.
Now if you have a lot of pain with your parents and it
warrants a surgery and endometriosis taken back, you
may get some fertility benefit from it.
But the reality is we tend not to do that.
But in general, endometriosis and its cousin adenomyosis,
(25:12):
which is in the endometriosis that's in the wall of the
uterus, those are things that are basically hyper inflammatory
conditions that can lead to difficulty implanting.
And there's different ways that we handle adenomyosis and
endometriosis depending on what kind of treatments people are
are involved in. But it definitely effects
(25:34):
implantation. It can make, even if you do
implant, for example, with adenomyosis, it can make the
placenta less effective at finding the bloodstream, which
can, which can compromise the growth of the baby over time.
So there are longitudinal problems that can happen during
a during a pregnancy, not just getting pregnant itself, but
(25:58):
trying to get through the pregnancy.
So those are all things that we consider when we're taking care
of people with these conditions.Wow.
Wow. Yeah.
And this, I mean, just to go into, you know, after loss too,
and, and hormones and things like that.
Many women, myself included, were prescribed progesterone
(26:21):
after loss. How common is that in the, you
know, to supplement that and meaningfully to improve
pregnancy outcomes? So the way that I talk about
this with my patients is to say,do I give progesterone in the
(26:41):
second-half the cycle when people are doing any sort of
treatment here? And the answer is yes.
But the reason I do it is not because I know it works, but
because there's not a lot of downside.
So people come to me and say my cousin had trouble getting
pregnant. They were given progesterone and
I had a baby and they had a baby, you know, And so there's a
(27:03):
lot of these associations that people have.
But what people don't realize isthat if someone has their
progesterone checked and it's low, we don't truly know if it's
low because progesterone is secreted in a, what they call a
pulsatile way. So, so if you checked it over
and over again over 10 hours, you get a wildly different
(27:25):
numbers. So seeing a low number is not
necessarily meaning that you've got a low progesterone level.
And if you truly did have a low progesterone level, it's likely
because the pregnancy was abnormal, not because you just
have a, you're not producing progesterone.
So I can give you progesterone, which fixes the progesterone
(27:46):
level, but doesn't fix an abnormal pregnancy.
So while we give it, I talk to my patients and say, look,
transparently, I don't know if this is helping, but there's not
a downside. If you were one of the very rare
people who had an issue with making progesterone, here it is.
But not to say that giving progesterone fixes an abnormal
(28:10):
pregnancy. So it's a little controversial.
Some people shy away from givingit.
I don't think there's really a downside to doing it.
So we often will give it to people.
But with the transparent angle to say, I don't know how much
I'm helping, but I'm not hurting, let's cover that as a
possibility. And so that's the, that's the
(28:34):
way I typically talk about it, yeah.
No, and I think that's great to understand, right, because even
thinking back when I, you know, was on it, they had there wasn't
really any risks or long term effects or anything like that
that, you know, and I'm gratefulto hear that it's still like
that, you know, Brian. Yeah.
The only thing that you have to be aware of is theoretically it
(28:55):
could delay a pregnancy, sorry, a bleed if you weren't pregnant.
Theoretically, when I see patients, they're coming to see
me for a pregnancy test. Yeah.
Specific time and so if their pregnancy test is negative, we
stop the medications. But if you're doing that on your
own, you could delay your pregnancy, your bleed after
(29:17):
negative pregnancy test a littlebit with it.
But I encourage people to just take the pregnancy test at home
if that's what you're doing. And if it's negative, stop it.
Yeah, most of the times we are. We're testing everything at.
Home too. Right.
Yeah. And you know, for the IVF like
(29:37):
reducing risks with miscarriage,you know, when we're having
reoccurring pregnancy losses, when does IVF with genetic
testing statistically reduce that risk and when might it not
significantly improve outcomes compared to natural conception?
Well, what I would say to you isI think the, the, the real
(29:58):
statement is to say it's a faster time to a successful
pregnancy. So it doesn't necessarily
increase the pregnancy rates, but the testing of the embryos.
But it does allow us to select an embryo that has the
capability of a live birth faster than if we didn't do
(30:21):
testing. So for example, if we had five
embryos to work with and they were not tested and two were
abnormal and three were normal, I am transferring an embryo one
at a time based on how the embryos look, the more the
grating and whether that embryo is normal or not is kind of
(30:43):
random. It's not necessarily related to
the grading. So I'm a one in five chance of
transferring it, you know, or two in five chance of having an
embryo that transferring an embryo that is the wrong number
of chromosomes, that is not going to work.
So I would say to you it's a faster time to a successful
pregnancy because I can select an embryo that has a or deselect
(31:07):
an embryo that. Cannot be right.
Yeah. Well and it's going into a very
evidence based, you know, based on seeing what you're able to
test with the embryos and everything ahead of time.
And with this testing, really all we're testing is the number
of chromosomes. I can't tell every little single
thing about an embryo. The way to the way to kind of
(31:29):
think about it is back-to-back to the encyclopedias that I can
tell if you have the right number of books in the
encyclopedia set. But I can't tell you in book 3
that chapter 2 is written backwards, right?
I can't tell little details, butI could tell the main building
(31:50):
blocks to say, look, this has the right number.
Once the don't have the right number or embryos that we should
have put, Yeah. That's good to know.
Thanks for clarifying that, Ryan.
And down to our last one and this is a big one.
I know that I saved this for last and we already were talking
about eggs a little bit, but this is what our community, you
know, we always feel like our eggs are on timers.
(32:12):
And I know we touched on it a little bit.
You know, when looking at if we're 36, it's really 37 for our
eggs because we're born with allof them.
You know, we hear about age and egg quality.
Are there biomarkers beyond AMH that better predict miscarriage
risk? And how do you counsel patients
without oversimplifying fertility decline?
(32:36):
I know it's a Josie. Well, I think what we, what I go
back to when I talk to patients is biology and I, I go through
the whole thing with all your eggs.
So over time there are, there are chances for eggs to become
abnormal over time. And remember, our parents
generation tended to have kids at younger ages, right?
(32:58):
And so maybe there was less of the age factor involved, whereas
our generation is a little different and people having
babies later in life, which now introduces more egg quality
issues over time. So the general idea is I can't
rate someone's quality of eggs. I can't say your eggs are an 8
(33:22):
out of 10. But I can say, look, your
birthday is what dictates the likelihood of having more good
eggs than bad eggs. And one of the ways that we know
all this information is not justthe fact that miscarriage rates
go up over over a woman's age. That's evidence that we have
(33:48):
abnormal embryos or abnormal eggs leading to abnormal
embryos. But the other is when we test
embryos to see if they're genetically normal, we have
certain expectations about pregnancy.
Sorry, Aneuploid rates the rate of an abnormal embryo based on
the woman's age. So at the age of 30, about 75%
(34:12):
of beautiful blastocyst embryos are normal.
At the age of 40, about 75% are genetically abnormal even though
they look fantastic. And 35 to 36 is where you have
that 50. So if a woman has 6 embryos and
(34:33):
she's 35, I'm going to say maybewe've got 3 normals in here.
If a woman's 40, we're starting to say a lot less.
And so, so I think it's important to talk about some of
that biology and some of the expectations.
But when people talk about AMHS,I love AMHS.
(34:53):
It's a great way of understanding your egg reserve
over time. It's a hormone that is made by
the cells that are around your eggs.
So the more eggs you have, the more cells around the eggs, the
higher the number. So AMH is a fantastic way to try
and get a feel for your quantity, but it doesn't say
(35:13):
that there's a problem with quality.
So if someone has a low AMH and they're coming to see me, I am
saying to you, you have a low amount of eggs.
I don't know that you have bad eggs in any way, shape or form.
If someone is 40, I'm worried about their eggs.
If someone's 30, I'm worried about them less.
AMH is really more so to say what's my reproductive longevity
(35:37):
as opposed to my quality. So I think understanding that if
you get a test, kind of understanding what it's telling
you is super important. So AMH is more related to your
quantity. AMH does not tell us if it's low
that you're not going to get pregnant.
Wow. I don't know if I answered your
(35:58):
question, but that. Yes, yes, you did, you did
absolutely. Thank you and thank you for
answering all these, you know, questions.
A lot of survivors in our community go through reoccurring
loss. So, you know, and, and when this
happens, it's always nice when we can give them an expert who
can answer some questions for them that they don't feel
(36:19):
comfortable asking or they're not ready to ask themselves.
So they give it to us. So we just can't thank you
enough for that, Ryan. And I would love for you to
leave our listeners with words of advice or any you know little
ending that you would like to. I would say to you, if you feel
(36:39):
like you're having trouble to reach out to somebody, certainly
with reproductive endocrinology,there are some aspects that we
don't have answers to. But many times we do have some
answers and we can certainly talk you through them.
And whether or not you do something about it is a
different story. But if you want to get some
(37:00):
answers, there are things that we can do to help you avoid
either difficulty getting pregnant or recurrent losses.
There's some treatments that arequite effective.
There are other situations wherethey're not, but the testing and
confiding in somebody is probably the first step.
(37:23):
Thank you. Thank you for leaving our
listeners with that. Sure.
And thank you so much for joining us today for sharing
your expertise, your perspective, and a deeper
medical understanding beyond, you know, reoccurring pregnancy
loss. Conversations like this matter
because they help families feel less alone and remind them that
their questions, their grief, and their search for answers are
(37:43):
valid. So thank you, Ryan.
Yeah, happy to help. Thank you to anyone listening
who might be navigating infertility, reoccurrent
pregnancy loss, miscarriage, still birth, any type of
pregnancy, or infant loss. Please know your story matters,
your baby matters, and your grief matters.
Healing doesn't follow a timeline.
Trauma and loss don't have a schedule, and you deserve
(38:04):
compassionate support through every step of your journey.
At Chasing the Rainbows, we provide daily support services,
free and community for families impacted by infertility,
pregnancy, and info loss. Because every loss matters.
If this conversation resonates with you, please share this
episode with someone who may need it.
And if you are looking for support, want to
(38:24):
volunteerdonateorhostaneventinhonorofyourbabyyoucanlearnmore@chasingtherainbows.org.Thank you for being here, for
listening, and for continuing tobreak the silence around
infertility and baby loss. Until next time this is cried
out loud, thank you.
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