Double Jeopardy: Infertility and Pregnancy Loss – Part I
By: Joann Paley Galst, Ph.D., Chair of the AFA Mental Health Advisory Council
After months or even years of hoping, trying, and waiting, your patience and persistence is finally rewarded when you receive a positive pregnancy test. But elation can turn to despair when this precious, most wanted pregnancy is lost, a loss that feels unspeakably unfair when superimposed upon a history of infertility.
Pregnancy Loss Expanded
Approximately one third of all conceptions end in an unintended loss, with around 80% of these losses occurring within the first trimester of pregnancy, 14% in the second trimester, and 6% in the third trimester. Assisted reproductive technologies (ART) have broadened the definition of pregnancy loss beyond the types with which most people are familiar, i.e., miscarriage and stillbirth. For example, if implantation does not result after an IVF embryo transfer, it may be experienced as a loss by the couple/individual, i.e., a preimplantation “miscarriage.” Chemical pregnancies occur when pregnancy symptoms are experienced (e.g., sore breasts, delayed period) due to ovulation-inducing medications used in ART treatments. Preimplantation genetic diagnosis results in preimplantation termination of genetically defective embryos prior to transfer.
The rates of multifetal pregnancies have increased with ART. A vanishing twin occurs before 14 weeks gestation when one fetus of a multifetal pregnancy fails to develop and is absorbed in utero. Multifetal reduction (MFR) is a procedure developed to terminate a pre-selected number of fetuses in a multifetal pregnancy to maximize the viability of the remaining fetuses and/or protect the health of the mother. After this procedure, parents may be faced with the challenge of experiencing grief (for this loss) and hope (for the remaining baby/babies), all during the same pregnancy, although most patients report being able to focus on having improved the chances of a healthy pregnancy and normal life for their remaining fetus(es). Couples and individuals may find little support in their community for these losses, however, often being told to “be happy you still have one.”
Issues of Pregnancy Loss Unique to the Infertile Population
Several factors put the infertile population at a higher risk for pregnancy loss. When an infertile woman conceives, she tends to be older than a woman conceiving spontaneously, increasing the risk of conceiving a baby with chromosomal abnormalities. Prenatal testing for these anomalies can also result in loss, although, thankfully, loss rates are relatively low, (~1.9% from CVS and ~1.4% from amniocentesis when performed by experienced physicians). There is an increased risk of loss for multifetal pregnancies, as well. It has been estimated that up to 15% of multiples grow up as singleton survivors after sibling(s) have died in utero. Unfortunately, there is approximately a 10% risk of losing the entire pregnancy when undergoing multifetal reduction. The increased risk of loss, as well as the couple’s willingness to undergo multifetal reduction should be discussed prior to treatment and should be taken into consideration when determining the number of embryos to transfer in an IVF cycle or whether a stimulation-insemination cycle should be cancelled because too many eggs were produced.
Recurrent pregnancy loss (RPL), also considered as infertility, is particularly troubling to the 1% of couples/individuals having three or more consecutive pregnancy losses before 22 weeks gestational age. Causes of RPL include hormonal, anatomical, infectious, thrombotic, genetic, or immunological reasons, or those due to sperm quality, although over 50% of cases remain unexplained. Even when no reason is discovered for the losses, however, there remains a 60% chance of having a healthy pregnancy after three miscarriages and a 40-50% chance after four miscarriages.
While most individuals/couples experiencing a pregnancy loss feel a sense of profound loss and grief, a loss of control, some feelings of social discomfort, and a need to make sense of their experience over time, those who have also been diagnosed and treated for infertility may experience a heightened sense of injustice and lack of fairness, as well as wondering if this, on top of infertility, means they are not meant to be parents. Since visualizing the baby on ultrasound can strengthen the attachment between parent(s) and baby, and those who have experienced prior infertility have likely seen their baby on ultrasound earlier and more frequently than those who have conceived spontaneously, this may also make a loss seem more real to them.
Along these lines is another issue for infertile couples/individuals, i.e., how long to wait to try to conceive again. Women who have been treated for infertility have a particularly high and more realistic fear that they may not be able to conceive again. Thus, many want to try to conceive immediately because of their age, length of time and treatment to get pregnant, or desire to avoid their grief. A recent study of full-term pregnancies in South America suggests that it may be safer for mother and baby to wait a longer period of time before embarking on a subsequent pregnancy, as intervals shorter than 18 months were linked to an increased risk of low birth weight, preterm birth, or small gestational size. Waiting longer also reduced the risk of the child developing health problems during the first five years of life. The authors hypothesized that a close succession of pregnancies did not allow the mother to recover from the nutrient depletion, blood loss, and physiological reproductive stresses of the preceding pregnancy before encountering the stresses of the next. However, critics of this study posited that the results were due to unstable lifestyles, inadequate nutrition, or a failure to use health care services. Waiting extra cycles to try to conceive can feel excruciating to those experiencing pregnancy loss(es). Emotionally, however, the individual/couple trying to conceive again does need to be psychologically ready to accept the possibility of another loss, as one never has a guarantee of pregnancy success, nor a guarantee of its failure for that matter, when embarking on trying to conceive. It is important to discuss with your doctor the advantages and disadvantages of waiting so that you can make an informed decision for yourselves.
Grief for a Pregnancy Loss Compounded by Infertility
Pregnancy loss combined with infertility can feel like punishment upon punishment, deepening the grief of a pregnancy loss. Ironically, however, while infertility typically intensifies the grieving over a pregnancy loss, the pregnancy loss may soften the impact of the infertility, as any pregnancy, even one that is ultimately unsuccessful, may result in the conferred status of parent, even if bereaved, which has been desperately sought, and can often give hope for the future. Recognition by others of these individuals as parents can acknowledge and validate the enormity of their loss and assist their grieving process.
Grieving the tragic outcome of your long-awaited pregnancy is both normal and necessary and takes far longer than most couples and individuals anticipate. It is a loss that often goes unrecognized by others as there are no publicly acknowledged objects to mourn and no socially accepted rituals. Unlike losses in which others can also remember the deceased, pregnancy loss is a projective loss for a baby only you and perhaps your immediate family “know.” You grieve not only for the baby/ies, but for the future hopes and dreams you carried of what was to come both for your baby and for you as a parent. In addition, you may already feel emotionally depleted from coping with your fertility challenges.
While grieving is a process and not an event, with everyone grieving in their own way and time frame, there are phases that many people circle through, moving both forward and back as they progress through their grief, including initial shock and denial, acute grief with accompanying vegetative symptoms (sleep difficulties, appetite loss, feelings of emptiness), chronic grief with possible feelings of anger, depression, guilt, and jealousy towards others, integration when you will start being able to remember your loss with less intense pain and find ways to integrate your lost baby into your life and begin to recognize the gifts that your baby has given to you (e.g., increased compassion for others experiencing loss; a deeper emotional connection with your partner), and anniversary grief wherein feelings of loss may be rekindled around significant dates and events e.g., your due date, date of conception, anniversary of your baby’s death, and even holidays and the change of seasons as they mark the passage of time.
Part II of this article will offer suggestions to help both you and your health care professionals to cope with these losses.
Joann Paley Galst, Ph.D., is Co-director of Support Services for the American Fertility Association and Chair of the AFA Mental Health Advisory Council. She is a psychologist in New York City specializing in reproductive health issues including infertility and pregnancy loss and a past Chair of the Mental Health Professional Group of the American Society for Reproductive Medicine. She is also a co-author of the recently released professional text, Ethical Dilemmas in Fertility Counseling, published by American Psychological Association Books.