Women having trouble getting pregnant face a daunting regimen of tests, protocols, and interventions. Infertility treatment isn't fun and doesn't always succeed. But as long as you can pay for it—or persuade your insurers to do so—there's a well-trod and involved path to follow, from taking the ovulation drug Clomid to in vitro fertilization. Treatment for women who can get pregnant but cannot stay that way, on the other hand, is neither standard nor readily available, and the reasons for this split between the wealth of infertility and dearth of miscarriage treatments are complicated.
When I miscarried three years ago, there wasn't much worth reading about the experience. That, at least, is starting to change. The collection The Friend Who Got Away, coming out in May, includes the essay "Other Women" about the loneliness of miscarriage; next year an anthology, About What Was Lost, will offer various perspectives and solace (including an adapted version of a Slate dialogue by Dahlia Lithwick and me). Suddenly, it seems, there's a burgeoning interest in miscarriage: both in talking about it and treating it. For those who want facts rather than emotion, there's also the new book Coming to Term by science writer Jon Cohen (who periodically contributes to Slate). Cohen explores the state of knowledge about why miscarriages occur and how they can be prevented. Along the way, he sheds light on why so few doctors and clinics offer miscarriage treatment that's like the Clomid-to-IVF route—and why that's not necessarily a bad thing.
In a sense, a policy of aggressive treatment for women who miscarry starts with two strikes against it. As any woman who has lost a pregnancy has been told—often more times than she can stand to hear it—miscarriage is nature's way. Pre-birth, it serves the Darwinian purpose of weeding the fit from the unfit. As many as half of conceptions and 15 percent of clinically recognized pregnancies are lost, according to Cohen, and between 50 percent and 70 percent of the time the loss is chromosomally abnormal. A treatment that disrupts this built-in purging mechanism could potentially result in more babies with birth defects; and that's probably not a treatment worth having.
Then there's the good news. Most women who miscarry, even three or more times, will eventually carry a baby to term nevertheless. Cohen cites a 1997 British study that puts the eventual success figure at 70 percent; other researchers have arrived at a percentage between 60 and 70. Would-be parents struggling through what feels like a never-ending cycle of disappointments can take heart from those statistics. But from the point of view of medical intervention, they set a high bar: To succeed in scientific terms, meaning across a group of women as opposed to anecdotally, a treatment for miscarriage must be shown to have a success rate higher than this 60-percent to 70-percent baseline, unless it's designed for a population of women who have been identified as higher risk.
Few of the treatments Cohen describes pass this scientific threshold. One theory about miscarriage holds that some women's immune systems go haywire and reject chromosomally normal fetuses because they detect the father's genes as a foreign intruder. Some doctors offer as treatment lymphocyte immune therapy, which involves injecting the pregnant mother with the father's white blood cells to somehow tame her immune system. Early studies seemed promising. The well-known doctor Alan Beer, whose satisfied patients include his own daughter, continues to swear by the therapy. But according to Cohen, in randomized, controlled studies lymphocyte immune therapy hasn't held up. Nor, so far, has progesterone—prescribed for a condition called luteal-phase deficiency, or letrazole, an estrogen-blocking drug that's supposed to help women with polycystic ovarian syndrome. Cerclage, which involves sewing up the cervixes (literally, with a needle and thread) of women with a history of early labor, is sometimes done when there's no evidence to suggest it will be effective. One of the problems of miscarriage treatment is that good studies are generally hard to come by—there's not much funding, and pregnant women often aren't eager to be the subject of research.
So, what's a conscientious obstetrician or midwife to do when faced with a patient who can get pregnant but who can't stay that way? Often nothing, in terms of simple medical intervention. (One exception to the rule is a proven treatment for women with antiphospholipid syndrome, who can increase their chances of carrying a baby to term with aspirin and the complex sugar heparin.) But if doctors and clinicians can't rush to write prescriptions, that doesn't mean they have nothing to offer their patients. In researching his book, Cohen learned of a dozen clinics around the world that specialize in caring for women who repeatedly miscarry. What seems to help many of their patients most is restraint, patience, and compassion. As Mary Stephenson at the University of Chicago Hospitals tells Cohen, "It's OK to want to phone a nurse every day."
And perhaps paradoxically, such non-clinical attentiveness has shown better results than any other treatment Cohen describes. One study in Norway of women who had miscarried at least three times (and some had miscarried as many as 13) found that 86 percent of those who received weekly medical exams and psychological support during a post-miscarriage pregnancy carried to term, as compared to 33 percent who did not. A separate New Zealand study replicated those results. Which may mean that, at least as a medical matter, hand-holding is the best intervention going for serial miscarriers.
The numbers of patients in the two studies is small, and Cohen expresses discomfort with a treatment that sounds, well, mushy—it goes by the cloying name of "tender loving care." But his wife, herself a miscarriage veteran, identifies strongly with the researchers' conclusion that the clinics succeed by confronting their patients' despondence, fatalism, and panic. One of the specialists Cohen shadows, Danny Schust at Brigham and Women's Hospital in Boston, doesn't even diagnose a specific problem in a third of his patients. That's OK: Until the science advances, a lot of women will settle for a knowledgeable hand to hold.
Those hands aren't always easy to find. Miscarriage isn't a specialty that pays well—with no big-ticket procedure to offer, the exams and counseling add up to a lot of time spent without much remuneration. The clinics that specialize in pregnancy loss often accept only patients who have miscarried at least three times. In policy terms, that's a sensible choice, given the numbers that show most women muddling through to a full-term pregnancy on their own. But for the minority who must wait for help as they try and fail again and again, each loss is its own measure of suffering.
Much about the science of miscarriage is still unknown. Cohen's book makes the case that the most useful advances will be better tests for those conditions associated with miscarriages—so that would-be parents and their doctors can know what they're dealing with. The majority of miscarriages shouldn't be prevented, and miscarriage specialists don't need their own version of a big-gun treatment like IVF. They need to know more about how to tinker with care around the edges of nature.