Coming to Term: Uncovering the Truth About Miscarriage
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Coming to Term: Uncovering the Truth About Miscarriage
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Overview
Approaching the topic from a reporter's perspective, Cohen takes us on an intriguing journey into the laboratories and clinics of researchers at the front, weaving together their cutting-edge findings with intimate portraits of a dozen families who have had difficulty bringing a baby to term.
Couples who seek medical help for miscarriage often encounter conflicting information about the causes of pregnancy loss and ways to prevent it. Cohen's investigation synthesizes the latest scientific findings and unearths some surprising facts. We learn, for example, that nearly seven out of ten women who have had three or more miscarriages can still carry a child to term without medical intervention. Cohen also scrutinizes the full array of treatments, showing readers how to distinguish promising new options from the useless or even dangerous ones.
Coming to Term is the first book to turn a journalistic spotlight on a subject that has remained largely in the shadows. With an unrelenting eye and the compassion that comes from personal experience, Jon Cohen offers a message that is both enlightening and unexpectedly hopeful.
Product Details
| ISBN-13: | 9780813540535 |
|---|---|
| Publisher: | Rutgers University Press |
| Publication date: | 03/28/2007 |
| Edition description: | ANN |
| Pages: | 296 |
| Product dimensions: | 6.00(w) x 9.00(h) x 1.00(d) |
About the Author
Read an Excerpt
Chapter 1
Not Viable
On a brilliant, warm San Diego saturday in the spring of 1996, my wife,
Shannon, had her first miscarriage.
Our baffling, heartbreaking journey into the world of what doctors
call "spontaneous abortion" began with a phone call. We were having a
lazy brunch with my parents on our front porch, pine trees shading us,
the Pacific Ocean visible in the distance. Our daughter, Erin, nearly six,
was chattering with her dolls in the pine needles. Paging my way through
the newspaper, I struggled to dodge conversation with my folks, who
were visiting for the weekend and would rather talk than read. Then the
phone rang, and Shannon excused herself to answer it.
Shannon is close to my parents, but had grown weary, as had I, of my
mother's well-meaning but insensitive probing about our reproductive
status. Any luck? my mother would ask, month after month, noting that a
cousin of mine recently had succeeded with in vitro fertilization. You really
shouldn't wait. You really should have started earlier. Maybe you should see a
specialist. Maybe there's something wrong with your sperm. Maybe you
should do IVF. I'll help you pay for it. You two should have another. It's a
shame. For Erin's sake. She shouldn't grow up alone. My kids always had
each other to play with.There must be something you can do.
So it was with great delight that a week earlier, we had Erin phone my
mother and tell her that Shannon, then thirty-seven, was pregnant. She
was only four weeks along, too early to see anything with an ultrasound
scan, but ablood test already had confirmed the positive urine test we had
done at home. We even had a due date. My mother squealed, really
squealed, with joy. She advised us not to tell anyone else until the baby was
three months along, but at every opportunity she exclaimed, "Finally!"
A few days after sharing the news, we drove to Los Angeles for
Passover dinner at my aunt and uncle's house. Erin had already leaked
the news to her cousins, and because Shannon's pregnancy with Erin had
gone so smoothly, we ignored my mother's warning, celebrating our
good fortune with all fifty of my relatives. Shannon also confided to my
uncle, a doctor, that she had been spotting blood, but that her obstetrician
had said it was common and usually means nothing. My uncle
agreed. "Everything is probably going to be fine," he said.
Shannon's spotting continued, and we read everything we could find
to help us understand first-trimester bleeding, which doctors often refer
to by the frightening phrase "threatened abortion." Sometimes, when the
embryo implants itself in the uterus it causes bright red bleeding for a
few days. But this blood was brown and had continued staining Shannon's
underwear for several days. Sometimes, bleeding occurs after intercourse
because hormonal changes make a pregnant woman's cervix
more exposed and delicate. Some women spot throughout their pregnancies
for no known reason and without any harm to the child or the
mother. Depending on whom you believe, 15 percent or 25 percent or 35
percent of women spot during their pregnancies and 25 percent or 35
percent or 50 percent of these women miscarry.
Obstetricians sometimes prescribe bed rest to prevent miscarriages,
but most often they do nothing. In part, the reluctance to intervene comes
from the diethylstilbestrol fiasco that surfaced in the 1970s. More commonly
known as DES, this synthetic form of the hormone estrogen was
widely used as a miscarriage treatment in the 1940s and 1950s. Reports
began to surface in the 1950s that questioned whether DES might actually
increase miscarriage rates, but the drug remained popular into the
1960s. In 1971, following a report that linked DES to a rare vaginal cancer
in female offspring of mothers who took the drug, a bulletin from the
U.S. Food and Drug Administration urged doctors to stop prescribing
DES to pregnant women. Subsequent studies have found that DES caused
infertility in exposed female children, genital abnormalities (of uncertain
consequence) in both males and females, and may also have increased
breast cancer in treated mothers. Recently, concerns have surfaced about
the health of DES grandchildren.
The day we returned from Los Angeles, Shannon saw her obstetrician,
who took a blood test. A six-week-old embryo should secrete increasing
levels of the hormone human chorionic gonadotropin, or hCG.
Home pregnancy tests turn positive when a woman's urine contains a
high enough concentration of hCG. The hCG keeps a pregnancy viable
by telling the body to keep producing two other hormones, progesterone
and estrogen, which help prepare the wall of the uterus for implantation
and prevent menstruation. The doctor told Shannon that if the embryo
was healthy, hCG levels should double every two to three days.
The phone call that Saturday morning was the doctor. "I'm really
sorry to tell you this, but your numbers have plateaued," the doctor told
Shannon. "It's not viable. You're going to miscarry within twenty-four
hours."
An ashen Shannon returned to the porch, and pulled me aside. She
whispered through suppressed tears, "Ask your parents to leave." Shannon
then went inside and fell on the sofa, forming a ball.
That afternoon, the intense cramps of labor walloped Shannon. By
evening came the heavy, seemingly endless flow of blood that marks a
first-trimester miscarriage.
Human beings are notoriously inefficient baby makers. A woman who is
trying to become pregnant will succeed, on average, one out of every four
menstrual cycles. According to a landmark study published in 1988, 31
percent of pregnancies end in miscarriage. So for each menstrual cycle,
a sexually active woman not using birth control has less than a 10 percent
chance of carrying to term. It is a wonder that we have an overpopulation
problem.
Shannon and I had never thought much about fertility. We quit using
birth control when Shannon was thirty-one (I'm five months younger),
and she became pregnant in her first cycle. I announced our good news
at my office, stupidly joking about how all I had to do was look at Shannon
and she became pregnant. A woman I worked with excused herself.
Later, she told me that she and her husband were having fertility prob-
lems. I learned fertility lesson number 1: your good news is not necessarily
good news to others.
Shannon's first pregnancy progressed precisely as described in the
stack of new books cluttering our coffee table. We marveled at each
ultrasound scan, thrilling at the window into the womb and each discernible
human feature of our creation. When the doctor put a microphone
on Shannon's belly, we delighted to the sound of our baby's
resonant heartbeat. At the baby store we bought not just a crib but, in a
joyous moment that underscored how certain we were that everything
would be fine, a beach chair for a one-year-old.
Everything was fine. Erin was born in Washington, D.C, at Columbia
Hospital for Women, with ten toes, ten fingers, and no complications
whatsoever. When we wanted another child, we figured, we would stop
using birth control again.
We didn't want another child right away. We both had demanding careers,
and we also wanted to return to our roots in California before
adding to our family. And four or five years between kids seemed like the
right spread, a chance for each child to enjoy our full attention.
In 1994, back in California, we rented a house with an extra bedroom
and abandoned birth control again. A few months went by, but no pregnancy.
The ob-gyn said not to worry: Given that Shannon was five years
older, the odds of becoming pregnant in a single menstrual cycle had
dropped from 25 percent to 10 percent. In a year's time, then, she should
be pregnant.
But after a year, we began to suspect that something was wrong.
Maybe it was me. I take a steroid, from time to time, to treat ulcerative
colitis. Or maybe it was Shannon. She takes strong drugs for her migraines.
Or Shannon's eggs. Or my sperm. Maybe we should see a fertility
specialist. Maybe we should listen to my mother and try in vitro
fertilization. Weighing these possibilities wore us down. Each of us felt
guilty for secretly hoping that the other person's body had caused the
problem. We worried that seeing a specialist would open a floodgate of
expensive, painful, and often futile interventions. Yet as the months
passed, I found myself lobbying for that option.
All that friction disappeared of course in the spring of 1996. Relief
washed over us when Shannon tested positive. But the miscarriage that
followed mocked us, illustrating how naïve and overconfident we had
been about our fecundity.
Six months later, more frustrated still, Shannon agreed to see a specialist
praised by a friend. At our first meeting, this likable doctor expressed
dismay about what she saw as our casual approach to the
pregnancy dance. "You're subfertile," she said. A woman's "fertility window"
begins to shrink dramatically at thirty-five, she explained. We
thought our odds would plummet after we turned forty, not thirty-five. The
"subfertile" label chagrined us. I, in particular, wanted to read the scienti
fic evidence behind the doctor's claims, which seemed to annoy her.
At the specialist's suggestion, Shannon started taking Clomid (clomiphene
citrate), a fertility drug that stimulates an egg to mature and
move to the surface of an ovary, the process known as ovulation. And on
the doctor's advice, I had my sperm checked. Normal count, the lab said,
but their swimming skills, daintily referred to as "motility," did not impress.
After a few cycles on Clomid with no success, we upped the ante
with intrauterine insemination.
On the carefully chosen day based on Shannon's ovulatory cycle, she
drove Erin to school in the morning, providing me with a few minutes to
deposit my seed into a sterile container before our doctor's appointment.
But shortly after Shannon left, a magazine editor phoned me with deadline
questions about one of my stories. When Shannon returned, the container
sat empty. She was livid. "I can't believe this," she said. "I have to
put my body through torture, and you can't even do the one thing you
have to do. You'll do it on the way."
"I can't do that," I said.
"Get in the car," she fumed.
So as we drove along the freeway, I tried to do my thing, but, well, it's
not easy when your wife is giggling at you and you're cruising down the
interstate, a pea coat over your lap, in clear sight of other morning commuters
sipping their coffee. As we exited the freeway fifteen minutes
later, I still hadn't made much progress.
"Damn it, do it!" barked Shannon. Somehow, I did, and just as I did,
I noticed a guy riding a bike staring at me.
We dropped off the container at the clinic and went out for breakfast
while the lab prepared my sperm for the procedure. When we returned,
Shannon changed into a flimsy hospital gown and lay down on the examining
room table. The doctors drew my sperm into a syringe and coupled
it to a catheter. A team of nurses and I watched as a doctor wiggled
the catheter up to Shannon's cervix and pushed the syringe plunger,
sending my sperm on the journey to find one of her eggs. This isn't making
love, I thought. It's making babies. The insemination failed. I was not
surprised.
We tried intrauterine insemination again at the peak of Shannon's
next cycle, which fell on Christmas Eve. There was holiday magic in the
air. Wouldn't it be wild? Again, no luck.
The side effects of Clomid limit the number of cycles during which a
woman can safely take the drug. By spring, Shannon had reached her
sixth and final cycle on the ovary stimulant. Rather than try intrauterine
insemination one more time, we opted for the natural approach--well,
seminatural, given the Clomid--and, lo and behold, her period was late.
But we did not rush to buy a $15 home pregnancy kit. Buying the kit at
first suspicion, we had learned, needlessly unleashes demons. A late period
has an ambiguity to it that a pee stick does not. Too many times we
succumbed to the delusional drama of the pee stick, watching the second
hand on the watch in frantic hopes that the test would turn positive. Too
many times had we felt completely deflated both by the result and by our
foolish willingness to, once again, embrace odds-defying optimism. Too
many times we ended up feeling like Lotto players holding a losing ticket,
cursing ourselves for having dumped money on a dream.
Our resolve gave way five days later, while vacationing in Mexico. We
finally found a urine test in a dust-covered box in a little-trafficked pharmacy.
We bought it anyway, and anxiously waited for Shannon's pee to
highlight the enthralling "plus" symbol on the blank white stick. The
stick soon showed a minus sign, but, in our delusion, we convinced ourselves
that it was really a minus sign with faint traces of the plus sign poking
out--if, that is, you held it in just the right light.
Were we winners or losers? On the plane home, Shannon started to
spot. Her period soon followed. Her doctor later concluded that she had
had her second miscarriage.
• • •
Several months passed, and fertility and miscarriage faded into the
background--at least I thought it had. One evening, Shannon asked me, her
eyes wet, mascara streaking down her cheek, whether I knew what day it
was. Had I missed our anniversary? "Our baby would have been due
today," she said, referring to the first miscarriage. I held her as she cried
and then wailed, with the particular grief that accompanies the death of
someone you love.
I suffered no lasting depression about that miscarriage. In my Cro-
Magnon way, I puzzled that she grieved so over a pregnancy that had
lasted a few weeks. Men and women do--must--have different reactions
to miscarriage, which adds yet another twist to an emotional rope that already
has many knots in it. I know more intimately than anyone else what
miscarriage meant to Shannon. But from another vantage, any woman
who has miscarried has a more precise understanding of Shannon's
sense of loss. A woman lives through a miscarriage. A man, no matter
how devoted, only observes it. So Shannon's reaction to an unborn baby's
birthday, a symbol that had little meaning to me at first, taught me something
about what miscarriage means to a woman.
Miscarriage for Shannon did not approach the most feared tragedy that
any parent can imagine: the loss of a child who actually breathes air,
snuggles into your neck, and looks into your eyes. But for me, the miscarried
embryo was an embryo. For Shannon, it was a son or a daughter, who, had
fate been more kind, would at that moment have fed from her breast for
the first time. It was that mercilessly real, and, though the pain eventually
did recede, I am certain that for her it will never entirely disappear.
In the fall of 1997, Shannon and I drove to Los Angeles for a concert by
Jackson Browne, whose music served as the soundtrack for our courtship
when we met in 1980. The next morning, I would leave on a three-week
trip to Congo, which was in the midst of a civil war. Our fears, mixed with
romance, created a mystical, fated mood.
I returned from Congo unharmed, and Shannon told me she was late.
Had we made a baby on a most perfect night? Was it simply a matter of
all the forces in the universe aligning themselves? I do not believe in any
such hooey, but for more than a moment I did. Shannon waited until my
birthday to take a pee test, and this one came out strongly positive.
"Happy birthday!" she announced, waving the stick in the air.
Shannon took her positive pregnancy stick to the doctor. "We love
when this happens," the nurse told Shannon before taking a confirmatory
sample of urine. After handing the nurse her sample, Shannon had
a consultation with her doctor, which the nurse interrupted. "I'm afraid
it's negative," she said.
The doctor added another phrase to our ever growing fertility playbook.
"You had a chemical miscarriage," said the obstetrician, explaining
that the advent of biochemically triggered pee sticks has allowed
many women to see pregnancies that otherwise would have gone by
unnoticed.
The doctor suggested that given Shannon's age and her reproductive
history, she had roughly a 3 percent chance of becoming pregnant
and carrying to term.
With those grave odds and three miscarriages in two years, Shannon
concluded that enough was enough. "Life is good," she told me. "I'm
about to turn forty. We have a family. Let's just leave it at that." I still clung
to hope, but agreed with her that we should quit actively trying to have
something that nature, clearly, did not want to give us.
There surely are bigger tragedies in life than not being able to have a
second child, and I soon accepted my lot in life, coming up with somewhat
tortured rationales for why I was happy that things had worked out
the way they had. If we really, really wanted another child, surely we
would have pursued adoption, which neither of us ever gave serious
thought. Although Erin was now only eight, it occurred to me that she
was almost halfway done with living under our roofwhich meant a return
to freedom for us. Whenever I was near babies, I suddenly recalled
how much work they required, and how much sleep they stole from their
parents. And if we had another child, our two-bedroom, one-bath house
would no longer work, requiring us to invest heavily in a remodel or a
new home.
Why then did I feel elated when Shannon suggested that we see one
more specialist? Because hope does not go quietly into the good night.
It lies on its cot, suitcase packed and ready to join us anytime we invite
it along.
Shannon's change of heart came about after she spoke with an old
friend who had had success with the most renowned fertility doctor in
town. "We should at least hear him out," Shannon suggested.
Entering the specialist's office, we noticed the requisite bounty of
baby pictures overflowing from his bulletin board. He met with us after
a forty-five-minute wait, guaranteeing us a 28 percent success rate if we
went with in vitro fertilization. I told him a 28 percent guarantee of success
equals a 72 percent guarantee of failure, and that our problem wasn't
getting pregnant, it was carrying babies to term.
Yes, he understood that, but Shannon was forty, and IVF would buy
us precious time by increasing the odds of a pregnancy per cyclefor
about $10,000 a pop. Before investing that sort of money, we agreed on
a set of tests to determine if either of us had any underlying reproductive
problems. The first order of business was a sperm sample from me.
This clinic required that I produce the sample on location. On an appointed
day, I joined a few other men in a special waiting room at the rear
of the doctor's office. We avoided eye contact. When my name was called,
a nurse ushered me into a media-equipped bathroom and showed me the
magazines (including a tattered seventies-era Hustler), a TV-VCR, and a
stack of porn videos. "Take as long as you'd like," she said. Right.
At our next consultation, the doctor said that because my sperm appeared
normal he wanted to perform a hysterosalpingogram on Shannon.
Neither of us had ever heard of this procedure, and the very sound
of it, reasonably enough, frightened Shannon. The doctor explained that
the test involved sliding a catheter into the uterine cavity, in the same way
that they did for intrauterine insemination. He then would inject a dye
into her uterus that would fill the fallopian tubes, allowing an X-ray to reveal
whether her tubes were clear. It would cause some cramping, he said,
but would not be painful.
We went downstairs for coffee while the doctor prepared a room for
the procedure. Shannon had a meltdown, crying inconsolably. "I don't
want to do this," she said. "We're done," I said, "that's it." When we told
the doctor, he tried to convince us that we were making a mistake, and,
unrelenting, he encouraged us to reschedule. "This isn't what we want
to do," I explained. His office later phoned again to reschedule. Then he
sent us a Christmas Card with babies on it.
In June 1999, Shannon and I attended the Matanzas Creek Winery's annual
Day of Wine and Lavender in Sonoma. The winery cultivates two
acres of lavender, the aromatic, glorious herb that many cultures have
celebrated for its healing properties. I put more faith in the healing powers
of wine. Booking a cabin in the nearby hills and renting a convertible, we
reveled in a kid-free, romantic weekend. Making a baby wasn't on the
agenda.
Whether it was the wine, the lavender, the combination, or the phase
of the moon, Shannon became pregnant that weekend. Urine tests are 99
percent accurate, but when she tested positive this time, we bought a second
pee stick and did it again. A blood test at the doctor's office showed
positive, too, and though it was too early to see the heartbeat on the
ultrasound, the obstetrician--a twenty-something man we called "the Kid"--
said he saw a "life form" on the machine. "Congratulations," he said, craning
his neck around the machine to see Shannon's face. "You're pregnant."
Despite our history, we started to tell people. It was such great news
that we just could not help ourselves. This time, we assured each other,
we would be spared the need to untell. This time, everything would work
out fine.
Two weeks later, Shannon returned for another ultrasound test. We
well knew the drill now: If they found a heartbeat on this scan, there was
a 95 percent chance that Shannon would carry a healthy baby to term. I
was out of town on a business trip, and Shannon phoned me from the
stairwell at the clinic. She was in a panic. "They couldn't find it," she
wailed. "He said, 'It's not viable.'"
Please don't be true, we bargained with fate. It can't be true. The Kid didn't
know what he was doing. This baby was just too perfect, conceived under
perfect circumstances after we quit trying. Shannon was forty-one. This
surely was our last chance. It had to be viable. It had to.
Shannon did not miscarry, and her breasts continued to grow. We returned
to the Kid for a confirmatory ultrasound. He turned it on, and did
a double take. "I don't know what this is," he said, pointing to a blob on
the screen, "but you better go downstairs to the bigger machine." The
fancier ultrasound revealed what looked like two embryos. But there was
no heartbeat. Still, we asked him to have his superior look over the films
that they saved from the scan. An elderly obstetrician phoned that afternoon
and confirmed the Kid's diagnosis. They both said Shannon would
need a D and Ca dilation and curettage, in which the doctor dilates the
cervix and then uses a surgical spoon called a curette to scrape out the
uterus.
Shannon wanted nothing to do with the D and C, and vowed to wait
out the miscarriage. At twelve weeks, on Labor Day weekend of all things,
she finally started to feel nauseated, had cramps, and miscarried. She was
grateful.
Two months later, in December 1999, Shannon again was late. We did
not bother to buy a pregnancy test. A few weeks went by, and our resolve
crumbled. The pee stick quickly turned positive. We did not even tell Erin,
nor did Shannon go see her doctor. After four consecutive miscarriages,
we assumed that the fifth was a given. It was just a matter of time.
Miscarriage, no matter how much we had accepted it, represented a
failure. A failure of my body or Shannon's or of our joint biochemistry, it
didn't really matter: try as we might, we could not make an embryo that
would attach to a uterine wall for nine months. That sense of failure I
think explains why adoption held little attraction for us. We did not simply
want another child. We wanted to beat what seemed a curse, to defy
the experts, to, in short, succeed. But after four miscarriages, failure had
thoroughly thrashed us, so much so that we both had a detached sense
about this fifth pregnancy, a hardened stance that said, in effect, if we do
not get our hopes up, failure will not be part of the equation. Call it denial.
Call it pragmatism. We were determined not to board the emotional
barnstormer, with all the nauseous loop-the-loops and barrel rolls, again.
But this pregnancy, unlike every preceding miscarriage, kept advanc-
ing just as Erin's had, just as the books described. Shannon's breasts
became tender and started to swell. She did not spot at all. She had morning
sickness. We bought two more pee sticks. Both turned positive nearly
instantaneously. At the first doctor's visit, Shannon already was nine
weeks along, and we intensely studied a monitor as a nurse performed
an ultrasound scan. We had become skilled at reading the foggy sonogram
images, but neither of us saw what we were looking for. The nurse
did. "There it is," she said, pointing to the fetus's pulsating heart.
With a heartbeat and a positive pregnancy test, the clinic shuffled us
to their obstetrician who handled high-risk cases. He performed his own
scan. "This one's good from the get-go," he said.
On August 6, 2000, Shannon gave birth to our son, Ryan Yisrael
Cohen.
Ryan's birth ended our personal battle with miscarriage, but the subject
still gripped me, especially given how much nonsense we had heard. I
decided to write the book that I wish had existed when miscarriage had us
in its throes.
Early in my research, I uncovered a fact that astonished me: when "recurrent
spontaneous aborters"--women like Shannon, veterans of three
or more miscarriages in a row--become pregnant again, they will, with
no treatment, carry to term nearly 70 percent of the time. Not only had
no one ever mentioned this major detail to us, but the underlying biology
baffled me. I studied miscarriage more intensively than I had during our
entire odyssey with this medical malady. I wanted to separate the many
myths that surround this most common event from the scientific studies
that carefully have attempted to illuminate one of the greatest mysteries
that exists about our bodies.
Investigating the causes of miscarriage drew me into the wonders of
reproduction, tracking each step of the journey: from sperm and egg uniting
into an embryo, to implantation, to viable fetus. Other species boast
much higher success rates. Reproductive biologists, in particular the
ones at the forefront of cloning, have begun to tease out more and more
clues about what it takes to carry a baby to term.
Scientific studies prove that abnormal chromosomes account for half
of miscarried fetuses. Research also clearly has established that eggs
more frequently present sperm with abnormal chromosomes as a woman
ages, which powerfully affects the increasing number of women who
now attempt to have children in their late thirties and forties. I sought out
both the researchers behind these studies and the couples participating
in them to better understand chromosomal problems and their intersection
with female aging, the single most common explanation for miscarriage
today.
I became intrigued, too, by the many theories that tie miscarriages to
aberrant immune responses. Still other studies implicate everything from
coffee to Advil to alcohol. Where did the truth lie? And what role did hormones
play, misshapen uteri, and infections?
As I delved deeper and deeper into the science of miscarriage, I was
astonished that so little is known. The dearth of solid answers helps explain
why so many unproven treatments have won wide acclaimand
remained popular even when evidence surfaces that they do not work.
Scientists first raised questions about DES in the 1950s, two decades
before its ban. Today, a wild, wild West mentality still exists in the
miscarriage field, an oft-ignored branch of medicine. Consider some of the
supposed "leading" clinicians who encourage recurrent spontaneous
aborters to inject themselves with their male partner's white blood cells.
A large, well-done study recently concluded that this experimental treatment
results in higher miscarriage rates than among subjects receiving
a placebo. Yet the treatment still is offered in some places. How could
this be?
While Shannon and other women who repeatedly miscarry and seek
help typically end up at fertility clinics, a dozen clinics devoted to recurrent
pregnancy loss now exist around the world and provide much more
appropriate care. As I spoke with the clinicians who run these clinics
and read their many scientific publications, I became intrigued by their
cutting-edge view of a problem that so many of their colleagues (many
of whom make oodles of money with fertility clinics) ignore. I quickly
saw, too, that recurrent loss plays the starring role in most miscarriage
studies.
Recurrent miscarriage plays a starring role in this book, too. Women
who have two, three, or, as befell one woman I met, seventeen, miscarriages
offer insights for others. Although most women who miscarry will
never have the experience again, as I discovered to my astonishment,
recurrent miscarriage hardly represents a rare event, as researchers long
have contended. As I will explain in some detail, modern miscarriage
detection techniques have uncovered this statistic: 50 percent of conceptions
fail, which means that at least half of all pregnancies fail, 25 percent
of women who attempt to become pregnant likely will have two miscarriages,
and 12.5 percent will have three. My intense focus on this group
reflects both this new reality and the fact that for the scientists unraveling
the mysteries of miscarriage, these women may hold answers that, if
identified, may help the population at large.
Finally, I began to pay attention to the networks of people who offer
emotional support for others who have suffered miscarriages, mostly
through chat groups on the Internet. Some have tragic tales of unrelenting
despair, while others, like us, have happy endings. Most everyone
reaches a tone of honesty and clarity that death, uniquely, ushers in.
Disease binds people. Look at the coalitions that have formed around
AIDS, breast cancer, and diabetes. But miscarriage, as common as it is,
does not qualify as a disease. It is not even a medical condition. That orphan
status, mixed with the taboo of discussing miscarriage and the
many scientific unknowns, feeds the loneliness and confusion that many
of us feel when we are in the throes of such a sad experience. I hope this
book will encourage people to talk more openly about their own miscarriages,
and that it also provides an accurate assessment of what science
understands, and what, as of yet, it does not.
The book weaves together personal stories with the most authoritative
scientific research that I could unearth, which I have divided into
three parts. After explaining my personal history and impetus for writing
the book, the first part, "Mother Nature," examines the fundamental biology
of reproduction, with close attention paid to the genetics, the single
most important driver of miscarriage. Part Two, "Mysteries," looks
closely at several leading theories about what causes miscarriages of
genetically normal embryos and fetuses, exploring in depth the various
interventions that attempt to prevent them. I first look at immune causes
of miscarriage and treatments, which range from the theoretical to the
proven to the disproved. Hormonal problems follow, again with a critical
eye cast toward the many experimental interventions now available,
and leading to a sobering look at how DES, a synthetic version of estrogen,
became a popular miscarriage drug. DES caused anatomical abnormalities,
but many others occur naturally, and I focus on their effects and
attempts to correct them. Part Three, "Hope," opens with an examination
of the long list of environmental and lifestyle factors that miscarriage
researchers have dragged down to the station house and put under the
harsh light. I then profile three clinics, each in a different country, that
specialize in miscarriage, describing what state-of-the-art care looks like,
as well as a myriad of patients who have many of the problems described
in earlier chapters. The book closes with a few of the most extraordinary
miscarriage stories I came across.
People repeatedly have asked me why women would want to read a
book about miscarriage written by a man. Well, why wouldn't they? And
why wouldn't men? If my book aimed to explain how it felt physically and
emotionally to miscarry, and how to handle the grief, I think a woman
writer who had experienced a miscarriage inevitably would offer unique,
powerful insights. But the questions that interest me most evade special
claim because neither gender knows more when it comes to puzzling out
how the human body works and devising strategies to help it when something
malfunctions. Why do miscarriages happen? Which interventions
work, which ones might, and which ones do not? Women and men alike
struggle mightily to unravel these mysteries. If one or the other has an
edge, I have not seen it.
I well recognize that Ryan is a gift, even a miracle, and that a happy
ending eludes many couples who struggle with miscarriage. Still, for couples
who have had miscarriages and still hold out hope, this book makes
the case that their prospects might not be as bleak as they seem. And
regardless of whether couples who badly want a child ever realize their
dreams, this book ultimately concludes that we all must come to terms
with our reproductive fates, which, try as humans might, we have less
control of than we would like.
Copyright © 2004 by Jon Cohen. Reprinted by permission of Houghton
Mifflin Company.