Sunday, April 20, 2008

Repeatedly losing pregnancy causes emotional strain

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Trying again after multiple miscarriagesKansas City -- Jennifer Freeman aches to have another baby. But she's worried. What if it doesn't work, what if she miscarries -- again?

"I just don't trust my body," she said.

Who could blame her? The first time Freeman, 27, got pregnant, it was joyous and seemed so easy.

She was 23, married for a year to her husband, Chris, an accountant, and living in Olathe, Kan.

When tests confirmed the pregnancy at four weeks, they were so thrilled they quickly ran out and bought a crib, told all their family and friends and picked out a name. If the baby was a boy, he would be Alexander Elijah.

Then, at eight weeks, the pain twisted inside her.

"I went to the emergency room," Jennifer said. "I was at work when it happened. It was a Saturday. The whole experience was horrible.

"A doctor, somebody, he said to me, 'A lot of people have miscarriages and they think it's so tragic; they think that it's like losing a baby.' To us, it was losing a baby."

Then she got pregnant again. In April 2005, when their son was born (named Alexander Elijah, in honor of their lost baby), the Freemans figured the first miscarriage was a fluke.

But then came a second miscarriage.

And last June 7, the worst of all: the premature birth at 32 weeks of another boy, Josiah Scott, who died two days later because of a frequently fatal chromosomal abnormality called trisomy 13.

Jennifer cradled Josiah in the hospital as he died.

"As soon as I held him, he calmed down," Jennifer recalled. "He knew I was his mom. I got to sing to him, 'Hush Little Baby."'

Now, as the anniversary of Josiah's birth and death approaches, the Freemans are in a situation familiar to a growing number of women.

Having already suffered what doctors call "recurrent pregnancy losses," they plan to try again very soon. But they're wary, anxious not only about why they continue to lose pregnancies and whether it will happen again, but also about their emotional reserves.

"It makes me very scared, the thought of going through that again," Jennifer said. "If I didn't have faith," she said of her and Chris' bedrock Christianity, "I think I would have lost it."

To be sure, the rates of single miscarriages (as opposed to recurrent) have remained steady for decades: 15 percent to 20 percent of all "recognized pregnancies," typically those after six weeks of gestation, end in miscarriage before the 20th week. If pregnancies before six weeks are included, the number rises to 50 percent. The odds of miscarriage increase as women age.

Less appreciated, experts say, is the extent to which recurrent pregnancy loss has become a visible part of the societal fabric.

Multiple miscarriages are thought to affect 1 percent to 3 percent of pregnant women, an overall rate that remains statistically unchanged. But experts say they suspect that the number of women who are experiencing recurrent pregnancy losses may be rising. The reasons are several, including better home pregnancy tests.

"Ten years ago a woman might wait past her first missed period, maybe two, before finding out she was pregnant," said physician Mary Stephenson, a professor of obstetrics and gynecology at the University of Chicago and director of its Recurrent Pregnancy Loss Center. "Now if someone misses her period by a day, she can go to the local pharmacy and get a very sensitive pregnancy test."

Not only is the result greater awareness of pregnancies, she said, but also greater awareness of when those pregnancies are lost.

The other main reason is advanced maternal age: the trend in the number of women waiting until their late 30s or even 40s to become pregnant.

According to the American College of Obstetricians and Gynecologists, as a woman ages her chance of miscarrying rises from 10 percent in her 20s, to 20 percent at age 35 to 39, to about 50 percent at 40 and older.

"If I know that there is a higher miscarriage rate for women in their 40s and more women in their 40s are attempting to get pregnant, I don't need a study to know the result: more pregnancy losses," said Gerson Weiss, professor and chair of the Department of Obstetrics, Gynecology and Women's Health at New Jersey Medical School.

"I used to see patients in their 20s who were asking, 'Why can't I stay pregnant?' Now I am seeing women 38 to 40's. It is a whole different picture."

Reliable statistics do not exist on the number of women attempting to get pregnant in their later 30's or 40's, but statistics on in-vitro fertilization kept by the federal Center for Disease Control and Prevention offer a picture.

In 1995, women 35 and older underwent 35,000 in-vitro fertilization cycles in an attempt to get pregnant using their own eggs. In 2006, the most recent statistical year, that number was around 62,000.

To women who try time and time again, only to lose their pregnancies, the emotional toll is tremendous. Deana Bender knows.

Now 52, Bender is a Kansas City dentist who several years ago sold her practice to dedicate herself to providing dental care to the indigent. When she was 31 and only recently married to her husband, Tom, she lost three tubal pregnancies in a single year.

Over the next six years, until age 37, she would lose four more pregnancies because of "messed up tubes."

"At the time it's happening, you're so full of emotions," Bender said. "You're deeply sad and angry. Why is this happening to me?"

Doctors can explain the causes of about 50 percent of multiple pregnancy losses: genetic disorders in older eggs, uterine adhesions or fibroids, even immune disorders. But in the other 50 percent of cases, the causes still remain mysterious.

For many women, breaking news reports on the possible causes of miscarriage only confuse matters.

In January, a study in The Journal of Obstetrics and Gynecology made national headlines with the news that pregnant women who drink 10 ounces of caffeinated coffee per day, or 25 ounces of tea, might double their risk of miscarriage. The story completely overshadowed another study, also published in January, but in the journal Epidemiology, that concluded the opposite.

"There is little indication of possible harmful effects of caffeine on miscarriage risk," the study's authors wrote.

As Deana Bender suffered one pregnancy loss after another, she began to wonder.

"Is this environmental?" she said. "Am I around stuff that is causing this? You start thinking, 'Is my water supply weird?"'

Meantime, relations with friends and family often become strained or even distant.

"What I see is that women who have more and more miscarriages become more and more isolated from their friends and family, even their parents," said Stephenson of Chicago's Recurrent Pregnancy Loss Center.

"I have many patients who don't tell their partners they are even pregnant, because they don't want to upset them or because their partners think it's futile or have lost hope."

The Freemans of Olathe said they have decided to not tell friends about their early pregnancies.

"I don't think most people even knew I had the second miscarriage," Jennifer Freeman said.

There is also the issue of negative judgment.

Bender acknowledged some people might question a woman who continues to keep trying to get pregnant in the face of such pain. What few understand, she said, is that no one starts out thinking they will have multiple pregnancy losses.

The first miscarriage doesn't seem unusual. Then comes the second. At the third, you start seeking treatment, Bender said.

"It becomes like someone with cancer," she said. "You think that with each new treatment maybe there's hope."

Indeed, for many women hope exists.

Sometimes surgery fixes uterine problems. Other times, a medicine helps ensure better implantation. Physicians continue to learn more about the use of low-dose aspirin and the anti-clotting medicines to combat specific immune problems.

In in-vitro fertilization there now exists preimplantation genetic screening that helps determine the genetic health of an embryo.

The tests are being recommended more often for women with recurrent pregnancy losses. But they are expensive and remain unproven and controversial.

After almost seven years of trying for natural childbirth, the Benders adopted newborns. Their son, Brant, and daughter, Blakely, are twins, now age 14.

"After going through all those losses, all those disappointments, I feel like it all worked out as it was supposed to in the long run," Deana Bender said.

As June approaches, the Freemans think of trying one more time.

"I just don't think I'm ready to give up yet, even if we have another loss," Jennifer said.


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