Abundant Spring

Recurrent Miscarriage


By Lee Hullender, MS, LAc, with contribution from Janci Karp, MSA and ND candidate


As a lifelong competitive athlete, Lauren* was used to achieving her goals. She had remarried at 41 and was mother to two beautiful daughters from a previous marriage. Lauren and her husband Michael wanted to have another child together. The anticipation soon turned to frustration. Each month they tried resulted in a positive pregnancy test and week four. This was followed by bleeding at week six and subsequent miscarriage. After three consecutive miscarriages, Lauren was starting to wonder what was the problem. She was healthy and very fit. She had worked hard all of her life to run and swim longer than her peers. Why am I unable to get off the starting block, she asked herself, and unable hold on to a pregnancy?

Not an entirely uncommon event, miscarriage occurs in 12 -15% of known pregnancies. This is not an entirely accurate statistic. It is estimated that nearly a third or half (depending on the statistical source) of all miscarriages occur without our knowledge, instead appearing like a late period. Thankfully, there is only a 1% chance that one will miscarry a second time. However, evidence supports an increased chance of miscarriage as the mother ages (see chart below).

Maternal Age (mother’s age)
Chance of miscarriage
18-20
12%
20-24
13%
25-29
14%
30-34
16%
35-39
19%
40-42
25%
43-46
50% or more


While a great deal of research supports the maternal age and miscarriage relationship, more research now strongly suggests that paternal (or father’s) age may also play a role. For women with male partners over 35, the incidence of miscarriage was more than double that of women with partners under 35.

In Lauren’s case, her husband was more than 10 years her junior. Despite being puzzled, she was resolved to succeed, and sought assistance from a fertility clinic. After several tests, she learned her follicle stimulating hormone (FSH) was elevated and that the number of developing follicles was less than ideal. She was also now 42 years old. The doctor explained this was normal for her age group and likely the cause of her recurrent miscarriages. He then matter-of-factly recommended she and Michael consider donor eggs.


Loss defined
In simplest terms, a miscarriage is a pregnancy involuntarily terminated before 20 weeks of gestation or if the fetal weight is below 500g. A loss after 20 weeks is considered a premature birth or stillbirth. The cause is generally different than a loss prior to 20 weeks. The risk of another miscarriage after three previous losses is actually much lower (30-45%) and varies with the number of previous live births: none, 40-45%; one or more, about 30%.

Miscarriage, also labeled as spontaneous abortion, is classified in many ways: threatened miscarriage, inevitable miscarriage, incomplete miscarriage, complete miscarriage and recurrent miscarriage.


Is it only age?

 

Age is a considerable factor, but there are several reasons for a spontaneous loss. Below are the common reasons and a typical western treatment approach.


Fetal genetic abnormalities: This accounts for nearly 50 to 75% of all losses and is often due to chromosomal abnormalities. Pre-genetic Diagnosis (PGD) In vitro Fertilization or donor eggs are often suggested.

Anatomic Factors: An abnormally shaped uterus, the presence or polyps, uterine fibroids, or adhesions can make it difficult for successful implantation or adequate blood flow to the gestational sac. This is often diagnosed by sonohistogram or hysterosalpinogram and often treated with surgery.

Immunologic disorders: Autoimmune disorders such as lupus, anticardiolipin antibody (ACA), antiphospholipid antibody (APA), antithyroid antibodies (ATA), and antinucliear antibodies (ANA), antisperm antibodies (ASA), increased natural killer cells and elevated levels of homocysteine. APA and ACA are often treated with aspirin and heparin therapy. Other immunotherapy includes intravenous immunoglobulin therapy. Hyperhomocysteinemia is managed with megadoses of Folate, B6 and B12.

Endocrine issues: include untreated or poorly managed metabolic diseases such as hyperthyroidism or hypothyroidism, uncontrolled diabetes, and polycystic ovarian syndrome. These diseases are usually managed with pharmaceuticals.

Bacterial infections: Bacterial Vaginosis, other pelvic infections (PID), mycoplasma, ureaplasma, Toxoplasma gondii, Listeria monocytogenes, and Campylobacter species. Treated with antibiotics.

Environmental influences: This is a broad section. It includes lifestyle behaviors as well as environmental exposures. Smoking more than 10 cigarettes a day is strongly associated with recurrent miscarriage. Drinking two or more alcoholic beverages a day or consuming 300 g or more of caffeine daily have also been implicated. Environmentally speaking, dry cleaning agents; solvents such as acetone, xylene, tricholorethylene: heavy metals like mercury and lead: benzo(a)pyrene (BaP), chemicals like ethylene oxide, chlorpyrifos (Durban), butylated hydroxyanisole (BHA), all found in various pesticides; and PVC plastics – these are all implicated in contributing or directly causing a miscarriage. For the lifestyle behaviors, smoking cessation and behavior modification are often prescribed.

 

Ancient Chinese wisdom
Not surprisingly, the Chinese culture has been using its medicine to treat new mothers faced with miscarriage for more than 2000 years. If there is a genetic abnormality, there is nothing that can be done. While this does not make the experience any easier, nature recognizes the delivery of a healthy baby is not possible in this case and self-corrects. Our job as practitioners is not to reverse this wisdom. Instead, we redirect the treatment focus to supporting the body through its natural process and prepare you for the next opportunity. We can offer help however when the rare situation arises in a threatened miscarriage due to the mother’s physiology. We augment the pregnancy with timely use of Chinese herbal medicine and acupuncture.

Like its western medicine counterpart, traditional Chinese medicine (TCM) categorizes the causes of miscarriage in several ways. It views a decline in vital energies as a significant contributing factor to miscarriage. Western medicine points to genetic abnormalities as the leading cause of miscarriage. In TCM, the Kidney** Essence (Jing), Yin, Yang, and Qi provide direction, energy and substance to the reproductive system. The quality and balance of these energies determine egg health in the female and sperm health in the male. Naturally, these energies decline with age, but they can be further damaged by poor care, overworking, poor diet, drug/alcohol abuse, excessive stress, and/or age. It is also possible a deficiency can be inherited at birth, as evidenced by congenital anatomic issues such as an abnormally shaped uterus or a shortened cervical canal.

 

Here are some other general relationships between TCM and western medicine:


Treatment options
The key to treatment from a Chinese medicine perspective is preparation and balance. Taking the time to address imbalances caused by aging, endocrine, immune systems, or clearing a blockage due to adhesions or polyps will ensure an increased fertile potential of each egg and sperm cell.

In general, treatment in the TCM modality includes weekly acupuncture for three months to support the full follicular development cycle, which is around 100 days. The best results occur with a combination of herbal treatment, weekly acupuncture, diet and lifestyle modification and dietary supplementation. The acupuncture and herbal treatment plan are customized to each patient’s needs.

When Lauren came to see me, she was exasperated at her options. She expressed her deep desire to become pregnant very quickly. My suggestion to take the time to prepare for her next pregnancy was met with understandable resistance. Instead, she chose to continue working with her fertility doctor and me. She did another round of clomid to no avail followed by a cycle with tamoxifien. This also failed. Lauren and Michael decided they were ready to prepare. They agreed to take three months and work on egg quality, calm her immune system, and prepare her body for a full-term pregnancy.

Lauren had used a great deal of her resources as an athlete and was stressed. While she was in great shape physically, energetically she was significantly imbalanced. This diminished her supply of vital energies to her reproductive system, limiting her egg quality. While still working with her fertility doctor, we focused only on acupuncture, diet, lifestyle and supplements. We focused on increasing her Kidney energy, addressing her stress and circulating her Liver energy, as well as circulating energy around her reproductive organs. She was already in a yoga for fertility class. This was helping her to breathe and support relaxation of the pelvic area and whole body. When she decided to stop taking medications to induce ovulation, I introduced herbal formulas for each phase of her cycle to support the groundwork we had already established. I also recommended Mayan Abdominal massage to help with uterine and ovarian blood flow. Lauren, being extremely motivated and used to regiment, was compliant and wholeheartedly pursued this treatment plan.

While every person is different, there are some common supplements I recommend to everyone:

  1. A high quality, high potency, multi-dose daily multivitamin. Deficiencies in beta-carotene, Vitamins C and E have been noted in women suffering from miscarriages. Folic acid, B-complex and minerals known for their antioxidant properties are also imperative. Avoid one-a-day vitamins, as their potency is compromised due to their limited absorption. Finally, drugstore brand vitamins are not high quality and often contain multiple ingredients that are poorly absorbed.

  2. Essential fatty acids are of paramount focus for a multitude of reasons. First, they help to minimize clotting. Second, they are an anti-inflammatory and are essential when dealing with immune disorders. Third, they help lower the bad LDL cholesterol, which can contribute to endocrine balance. Finally, they are excellent for the baby’s brain development. Take 2500mg EPA/DHA daily and can be taken through pregnancy and beyond. You can get this from fish oil. Ensure it is third party tested for PCBs, lead, mercury, cadmium, and other heavy metals. Choose an oil made from the whole fish over cod liver oil.

  3. Antioxidants are essential when addressing egg quality. Not only are they helping to reverse the effects of stress, but they are also muting a hyperactive immune system. Oxidative stress has been implicated as a significant factor in egg quality. Oligomeroproanthocyanidins (OPC) are exceptional antioxidants. Take 50 to 60mg per 60 pounds of body weight for two weeks; thereafter, decrease your dose to 50 to 60 mg per 120 pounds of body weight. These can be taken safely throughout your pregnancy. Other great antioxidants include zinc picolinate, alpha lipoic acid, bioflavonoids, selenomehtionine, B6, B12, Vitamin C, Vitamin E, and beta-carotene.

Here are some other supplements I may recommend:

  1. Coenzyme Q10 is a cofactor that improves cellular processes. It works on the organelles within the cell to improve its metabolic performance. CoQ10 is an excellent supplement for all ages, but especially women over 35. Consult with your practitioner for dosage. Discontinue once you become pregnant.

  2. L-Arginine is an amino acid that assists in vasodilation, which can increase blood flow to the uterus and ovaries. Because it is water soluble, the dosage is fairly high at 6g daily. Discontinue once you become pregnant.

Another large component of the treatment plan focused on Lauren’s need to succeed at any cost. She at one point expressed great dismay at the possibility of failure. It was not generally in her vocabulary. She had always finished what she started. Chinese medicine looks not only at the physical and energetic balance, but also the emotional and spirit balance. Over time, Lauren was able to transform herself away from “failure is not an option” to allowing the process to happen. She was able to grieve the losses and become hopeful. She began to accept either outcome and release the rigid expectations of herself.


Some suggestions during a miscarriage
During a miscarriage, adequate rest, removal of stressors, and proper nutrition are imperative in supporting the body through the process. A diet high in fruits and vegetables (organic when possible) gaining optimal levels of antioxidants, purified water, hormone and antibiotic free animal proteins, and low sugar intake will provide support to the body. Increased intake of iron foods and foods rich in Vitamin C and Vitamin E are also appropriate. Foods to avoid during this time include spicy and fried foods, salty foods, caffeine, alcohol, dairy, and refined foods. Also during this time, a woman should be checked regularly by her midwife/physician to assure that all products of conception have passed and signs of infection are being monitored.

Specific nutritional deficiencies have been associated with miscarriage and/or prevention of miscarriage. Low zinc intake has been seen with spontaneous abortion and premature delivery. Bioflavonoids and Vitamin E supplementation has been shown to prevent miscarriage, decreasing leakiness and breakage of small blood vessels and providing protection against free radical damage. Selenium is another important nutrient to supplement. A multi-vitamin and mineral compound suggested by your midwife/physician is important for providing the appropriate levels of nutrients needed before, during and after pregnancy.

Traditional herbal medicines have been used for support in preventing miscarriage. Your midwife/physician can make appropriate recommendations based on your individual needs. Black Haw has relaxant and sedative effects on the female reproductive system. It is often used when there is tension and stress in those organs. It sedates the uterus and halts contractions. It has been used traditionally in preventing miscarriages. There are no known reports of toxicity or side effects in using black haw. The root can be infused as a tea. In can be ingested as soon as pregnancy is known, and throughout the duration if desired. False Unicorn Root is another herb that has beneficial effects on the female reproductive system, especially pertaining to miscarriage. It is considered amphoteric is action, helping to normalize and balance hormone production. It is considered a uterine tonic and is often used in formulas to prevent miscarriage. It is a reproductive tonic and stimulates uterine and ovarian function. This herb is often used from pre-conception through the first trimester. Wild yam root has been traditionally used for prevention of miscarriage as well. It is known for its effect on regulating hormone production. The plant provides constituents that are essential building blocks needed in the production of both progesterone and cortisone. It aids in regulating the ratio of progesterone to estrogen in the female reproductive system. Again, your midwife/physician can provide appropriate dosage recommendations based on your needs for the above herbal medicines, as well as provide additional herbal suggestions.

Miscarriages can be an act of nature, as a natural selection process if a fetus is not biologically healthy to withstand life. In other cases, miscarriages can be prevented at times, if the causes are investigated thoroughly and addressed appropriately. Treatment programs can be designed based on a couple’s present state of health and well being to promote a healthy and viable future pregnancy. These treatment plans can include lifestyle suggestions including diet and exercise, botanical medicine, and homeopathy. Consult a midwife/naturopathic physician to design a program specific for you.


Conclusion
Lauren and Michael after two months of treatment became pregnant and unfortunately miscarried at six weeks for a fourth time. While it was difficult, Lauren was more at ease with this loss. We spent two more months with treatment, enough time for a full follicle development cycle (three and a half months). Lauren became pregnant once more during the fourth month of treatment. She is finally off the starting blocks and doing well in her second trimester.


Resources
Here are some great books about miscarriage, coping.

  1. Coming to term, by J. Cohen.

  2. Trying again: A guide to pregnancy after miscarriage, stillbirth and infant loss, by Douglass and Sissman.

  3. Pregnancy after a loss: A guide to pregnancy after miscarriage, stillbirth or neonatal death, by C. C. Lanham.


Notes:
*Not her real name.
**When organs are used in Chinese medicine, we are referring to the energetic function of the organ, not the anatomic or physiology of the organ (although there is some overlap). Dr. Lewis’ book, “The Infertility Cure,” has an excellent chapter describing these functions from the Chinese medicine perspective.


Bibliography:

Gladstar, R. Herbal Healing for Women. Simon & Schuster. 1993.

Hudson, T. Women’s Encyclopedia of Natural Medicine. Keats Publishing. 2004.

Hywood, A. Natural Fertility Management – Integrative Medicine for Female and Male Infertility. Seminar. Bellevue ,WA. 2005.

La Rochebrochard E, Thonneau P. “Paternal age and maternal age are risk factors for miscarriage: results of a multicentre European study.” Human Reproduction. June 2002. 17:6, 1649-1656.

Lewis, R. The Infertility Cure. Little, Brown and Company. 2004.

Lyttleton J. Treatment of Infertility with Chinese medicine. Churchill-Livingston. 2004. 277-336.

Marz, R. Medical Nutrition from Marz, 2nd Edition. Omni-Press. 1999

Pizzorno, J, et al. Textbook of Natural Medicine, 3rd Edition. Churchill-Livingstone. 2006.

Speroff L, Fritz M. Clinical Gynecologic Endocrinology and Infertility. Lippincott, Williams & Wilkins. Seventh edition. 2005. 1070-93.

Trickey, R. Women, Hormones & the Menstrual Cycle. Allen & Unwin. 2003.



Lee Hullender, MS, LAc, Dipl. OM, is an acupuncturist and herbalist in Bellevue, WA. She practices out of her own Bellevue clinic, Abundant Spring Fertility Acupuncture, and a fertility clinic, Northwest Center for Reproductive Sciences, Kirkland, WA. Her entire practice focuses on treating male and female fertility issues. She resides in Seattle with her husband and dog.Email her at info@abundantspring.com. Learn more about her practice at www.abundantspring.com.

Janci Karp is a 2007 Naturopathic Doctor and Master of Science in acupuncture candidate at Bastyr University. She preceptors at Lee’s clinic.

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