The first time Patricia McCreary became pregnant, she had a baby."I look at that now as this naïve bliss time, when I thought pregnancy meant a baby," said Ms. McCreary, who lives in Seattle.
But five years and four miscarriages later, she said, "When I hear someone say, 'I'm pregnant,' to me it's like, fear and dread and when am I going to get my heart smashed."
The agony of infertility for thousands of American women is not that they cannot conceive, but that they cannot hold on to their babies beyond the first few weeks of pregnancy - and no one can explain why.
Doctors say that as many as 3 or 4 percent of couples who try to have children suffer from what doctors call recurrent pregnancy loss, in which women younger than 40 experience three or more consecutive miscarriages with the same partner.
A fourth of those couples, doctors say, will probably remain in the "don't know why" category. Researchers at the Centers for Disease Control and Prevention estimate that of the 6.23 million pregnancies recorded in the United States in 1999, 1 million ended in miscarriage. A 25-year-old has a 15 percent chance of miscarrying. By 42, that figure exceeds 50 percent.
Miscarriages, though common, are rarely discussed. Nor have they been much studied until recently.
In most women, miscarriages occur because an embryo with genetic abnormalities is not viable, and that is also true for some losses among women who miscarry often. In those cases, women can opt for in vitro fertilization and pre-implantation genetic diagnosis. That ensures that only embryos deemed genetically normal are implanted in the uterus.
Other causes of recurrent pregnancy loss include anatomical abnormalities in the uterus, diseases of the immune system, hormonal imbalances and problems with blood clotting. Infections and, more rarely, chromosomal abnormalities in a parent, can also be factors.
Patients and doctors say that treatments can differ wildly from practice to practice and that there is only a limited consensus on how to address unexplained recurrent pregnancy loss.
"Doctors forget to order the very basic tests, check the uterus," said Dr. William H. Kutteh, a specialist in immunology and reproductive endocrinology at Fertility Associates of Memphis. Over half the women Dr. Kutteh sees with recurrent pregnancy loss, he said, have never been given a cheap, simple test for insulin resistance, although that problem is associated with higher miscarriage rates.
Even a treatment as venerable as progesterone, a hormone vital to a healthy pregnancy, is divisive. Some doctors swear that it helps. Others argue that it does nothing but postpone an inevitable miscarriage. New research suggests that very high doses of progesterone may be effective in some cases, probably a result of the hormone's immunosuppressive effects.
"How many patients do we save from miscarriage with progesterone supplements?" Dr. Alan B. Copperman, director of reproductive endocrinology and infertility at the Mount Sinai Medical Center, asked. "Not that many. Do we do it routinely? Sure we do. It's a mostly harmless, inexpensive treatment, which a lot of patients go on. But it probably doesn't save that many pregnancies."
Dr. Kutteh said that when he was a student 15 years ago "there was no training on pregnancy loss."
"It's just one of those areas where there wasn't much known," he added. "And there were not many experts, and there was not a consensus on what to do."
Now, he said, more than 25 training programs turn out about 50 specialists a year.
Despite exhaustive testing to find a cause, many miscarriages go unexplained. This was the case for Ms. McCreary and for Isabel Letsch, 25, of Baltimore, who has charted the reproductive history of her three miscarriages after failed fertility treatments in a Web log, Isabel's Journal.
"It's just a big mystery," Ms. Letsch said. "My doctor has given up hope and told me it's because I'm overweight."
No data support that diagnosis, she said, adding:
"I know I can get pregnant. I've never got as far as to see a heartbeat. We know it implants. It just doesn't develop any further. We're just kind of frustrated."
Full Article: http://www.nytimes.com/2005/02/08/health/08baby.html?pagewanted=2&adxnnl=1&adxnnlx=1203446180-dmaEtkRBFH5sURiqYQhshg
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