Miscarriages are, unfortunately, extremely common these days. It’s estimated 1/3 women experience miscarriage, though the number could be up to 50 percent. Miscarriage can be triggered by many different things and while the ‘reason’ behind a miscarriage may not always be possible this post is meant to serve as a general overview of the most common causes of pregnancy loss (along with testing & treatment options) to help you prepare for a healthy pregnancy moving forward;

MTHFR deficiency

MTHFR deficiency refers to a mutation in the genes responsible for metabolizing folate, a vitamin found in your prenatal supplement that helps to prevent spina bifida. When folate is not metabolized properly it results in a buildup of an amino acid called homocysteine, which can cause blood clotting and inhibit uterine & placental blood flow.

• Testing: genetic screening (this can be done through an analysis of your 23&me results), or elevated homocysteine / B12 levels in your blood work. Note; this refers to high levels without taking B12 as a supplement, it’s normal for levels to be high when supplementing but very high levels may indicate that the B12 isn’t crossing into the cell due to MTHFR issues.
• Signs: people with the MTHFR gene sometimes also experience low mood and low energy.
• Treatment: a diet rich in dark leafy greens, methylated pre-natals vitamins, avoidance of synthetic folic acids, a paleo-style diet.

Anti-phospholipid syndrome

Antibodies from your immune system attack components of your blood vessels in the uterus causing pregnancy loss. These antibodies interfere with uterine blood flow and inhibit placental development (specifically the trophoblast).

• Testing: blood testing for abnormal antiphospholipid antibodies, this must be done through your fertility clinic or specialist. Examples of anti-phospholipid antibodies include: lupus anticoagulant, anticardiolipin antibody, and anti-B2 glycoprotein.
• Signs: repeated pregnancy loss which continues to occur after a significant fertility workup has ruled out most other causes (see below), some women also experience numbness & tingling in the face, arms & legs or a history of blood clots.
• Treatment: anti-coagulate or anti-platelet therapy, depending on the severity or type of APS. Promising new research also recommends adding statins and hydroxychloroquine to anti-coagulant therapy. Mild APS may be treated with low dose aspirin and / or high quality fish oils.

PCOS

Women with PCOS typically have insulin resistance, which interferes with ovulation, follicle maturation, and maintaining a pregnancy. Insulin resistance has been linked to poor egg quality, pelvic inflammation, and progesterone deficiency, all which contribute to miscarriage.

• Testing: DUTCH hormone testing, blood testing (DHEA, HbA1C, free testosterone, ESR, CRP testing) Note: ultrasounds can be useful but only about 30% of women with PCOS actually present with cystic ovaries so a clear ultrasound does not rule out PCOS.
• Signs: to be diagnosed with PCOS a woman must also present with a few of the following clinical symptoms in addition to lab work: excessive hair growth on face or body, anovulatory cycles or missed periods, weight gain, acne + oily skin, hair thinning.
• Treatment: Metformin is often prescribed to women with PCOS but the research has not actually shown this drug to be particularly beneficial in preventing miscarriage in PCOS. There are many promising natural treatments for PCOS & fertility including CoQ10, inositol, NAC, zinc & dietary changes.

Chromosome translocation

This genetic condition can occur due to either sperm or egg quality. If you have a chromosome translocation you won’t have any signs or symptoms, but some of the gametes you produce (i.e. egg or sperm) will also have these genetic changes. Typically the body will terminate a pregnancy early on if the embryo has genetic changes that will result in a baby with chromosomal translocation.

• Testing: Blood samples are collected from each parent and analyzed for translocation, this testing is typically done through your fertility clinic but a functional practitioner with training in genetic medicine can use your 23&me results to screen your genetic profile.
• Signs: early pregnancy loss with no other underlying conditions or signs of symptoms.
• Treatment: patients with specific genes that make it more difficult to have a healthy baby can be referred to a fertility clinic for IVF where embryo’s can be tested for genetic abnormalities, supportive care with a naturopathic doctor is an asset.

Hypothyroidism & Hashimoto’s

The reference range for TSH is anywhere from 0.3 – 4+ but the American Endocrine Society considers a reading <2.0 to be optimal for fertility. TSH greater than 4.0 during pregnancy is associated with miscarriage, preterm birth, premature rupture of membranes, and placental detachment. Even minimal hypothyroidism can increase rates of miscarriage and may also have adverse effects on babies’ future cognitive development. Thyroid peroxidase antibodies, found in Hashimoto’s thyroiditis, can cause similar outcomes with no changes to TSH levels.

• Testing: request a full thyroid panel from your naturopath or fertility clinic, including TSH, free T3, free T4, anti-TPO & antithyroglobin. If your medical doctor refuses to run ALL of these tests you can order a full thyroid panel from your naturopathic doctor for around $150.
• Signs: pregnancy loss <12 weeks (when the baby’s thyroid starts working on it’s own), cold temperature, depression, weight gain, fatigue, hair loss, brain fog.
• Treatment: thyroid hormone replacement (levothyroxine or ERFA / Armour) + natural therapies to reduce thyroid antibodies.

Vitamin & Nutrient Deficiencies:

• Vitamin D: vitamin D deficiency has been identified as a risk factor for miscarriage, preterm birth, and low birth weight. Adequate vitamin D levels, are hard to come by in gloomy Canada and extremely important when it comes to reproductive health. One study showed that every 1nmol increase in serum vitamin D levels decreases miscarriage rate by 1%.
• B12: low serum B12 is associated with recurrent pregnancy loss, typically within the first 5 weeks of a pregnancy. B12 works with folate to synthesize DNA, RNA and red blood cells & adequate levels of B12 maximize the uptake of folate, which is critical for baby’s nervous system development. B12 has also been shown to support endometrial lining for healthy implantation.
• Iron: Iron’s role is to carry oxygen around your body, which is obviously very important for growing a healthy baby. Lack of oxygen delivery affects the baby’s health, prevents proper placental development, and increases the rates of miscarriage and preterm birth. Ideal numbers for fertility are >50ng/ml.

Anatomical causes

Anatomical issues, such as fibroids, polyps, uterine malformations and cervix incompetence are some of the most common causes of second trimester losses. They effect the body’s ability to allow for fetal growth and to keep the baby in the uterus until it has reached full term.

• Testing: a pelvic ultrasound can diagnose most anatomical causes of recurrent pregnancy loss. You doctor may also do a cervical swab to look for certain types of bacteria that can impact your cervix’s ability to maintain a healthy pregnancy.
• Signs: pregnancy loss in the second trimester, fibroids typically cause heavy periods but most other anatomical causes are free of any signs of symptoms and must be diagnosed via ultrasound.
• Treatment: surgery is typically indicated in the case of very large fibroids, polys or severe uterine malformations. If surgery is not possible your fertility team will be monitoring you more closely once they confirm the presence of anatomical issues that may impact pregnancy outcomes. Herbs and nutraceuticals can be helpful for reducing fibroid size when trying to conceive, but you’ll need a few months for the therapies to work. Antibiotics along with vaginal probiotics can resolve bacterial causes of cervix incompetence.

Poor quality sperm

Sperm are sensitive to environmental factors and can be damaged during sperm production and transportation. This damage is known as DNA fragmentation & high levels of sperm DNA fragmentation have been shown to double the likelihood of a miscarriage.

• Testing: the best test for measuring sperm quality is called sperm DNA fragmentation. Greater than 25% fragmented DNA indicates poor quality and is typically due to lifestyle factors like diet, alcohol, medications & drug use. Anti-depressant medication (specifically SSRIs) have been shown to cause statistically significant rises in DNA fragmentation increasing the risk of miscarriage.
• Signs: this one is hard to tell by looking at physical symptoms alone, testing is your best bet!
• Treatment: Luckily sperm is typically highly responsive to vitamins, supplements and lifestyle factors like quitting smoking, starting an exercise routine or cutting alcohol intake down to less than 4 drinks weekly.

Poor quality egg

Poor egg quality is caused by diminished ovarian reserve (aka age), pelvic radiation, surgery, reproductive illnesses, genetic abnormalities, chemotherapy, excess consumption of tobacco, alcohol & possibly environmental factors like food quality and stress.

Egg quality is important because it determines embryo quality; poor egg quality is closely associated with chromosomal abnormalities in embryos, which often lead to the body choosing to abort that pregnancy. Poor-quality eggs can be fertilized, but may not be able to implant, or the embryo initially implants, but is unable to develop properly resulting in a miscarriage. Though women >35 are more likely to have poor quality eggs younger women can have issues as well.

• Testing: AMH testing can show you whether your ovaries are aging more quickly or more slowly than average but a woman with abnormal AMH levels can still conceive a healthy child (although, she may not want to wait until her 40’s to do so ..). Research shows that ovarian reserve testing is only useful when it comes to determining a woman’s chances of success at harvesting eggs for egg freezing or for IVF but they are not a good predictor of a woman’s ability to conceive through natural methods. Other useful blood tests include FSH, progesterone & estrogen, which can all give us a general sense of egg quality.
• Signs: age is the number one predictor for egg quality (steadily declining after age 35) – but don’t worry, there are lots of natural therapies that can help. Women with poor egg quality may also experience irregular periods, abnormally long cycles or very light or heavy menses, all of which indicate issues with ovulation.
• Treatment: DHEA, bio-identical progesterone, supplements, herbs & acupuncture can all support ovarian quality in women with recurrent pregnancy loss. If poor ovarian quality is combined with suboptimal sperm health the patient may want to consider IVF.

Inflammation & Oxidative stress

Endocrine conditions like PCOS, thyroid disease, obesity and endometriosis can all cause increased uterine inflammation and oxidative stress, making it more difficult to have a healthy pregnancy. Excessive inflammation has been associated with recurrent miscarriage and other pregnancy complications such as pre-eclampsia

• Testing: ESR & CRP are general screening markers for systemic inflammation, they’re cheap (around $5 each) and can be run through your naturopathic doctor or fertility clinic. At replete wellness we like to dive into a patient’s genetic results to see if they’re more likely to have high levels of inflammation as a cause for miscarriages (there are genes relating to oxidative stress, inflammatory cytokines and detox capacity all available through your 23&me + health data profile, we just need to poke around the raw data to get to the important information).
• Signs: uterine inflammation can present with vaginal bleeding or discharge, constipation or pain with bowel movements & swelling in your abdomen. Systemic inflammation can cause joint pain, lethargy, weight gain, skin issues and depression.
• Treatment: there is tons of research on natural anti-inflammatories and antioxidants to help increase live birth rate and prevent miscarriage. Some of the mostly commonly prescribed treatment options include; ACES + zinc vitamin combos, fish oil, CoQ10 & an anti-inflammatory diet.

Progesterone deficiency + Emotional stress

Progesterone helps the female body maintain pregnancy in the early stages and helps to prevent miscarriage. This hormone occurs naturally in the body; it’s created through ovulation prior to pregnancy and is secreted by the corpus luteum during the first trimester of pregnancy followed by the placenta in the later phase of pregnancy. Stress + low progesterone go hand & hand since high stress directly impacts progesterone production thereby increasing a woman’s chance of miscarriage. When your body is stressed it makes high levels of cortisol. Progesterone and cortisol are both made from pregnenolone which means that when cortisol levels increase, progesterone levels naturally decrease.

• Testing: blood testing of progesterone can be somewhat unreliable but it’s still your best bet if you’re currently pregnant and wanting to monitor levels. Ideal levels in the first trimester range from 100 – 280 nmol/L. DUTCH testing (ie urinary hormone metabolite testing) is our go-to test for progesterone + all the other sex hormones involved in fertility and conception. It’s ideal for use in non-pregnant women looking to optimize their hormones before resuming trying to conceive after a miscarriage.
• Signs: low progesterone can cause heavy, painful periods, short cycles (<25 days), PMS, anxiety, weight gain and difficulty maintaining pregnancy in the first 12 weeks.
• Treatment: progesterone can be taken as a shot, pill or vaginal suppository (our preference) until week 14 to maintain levels. Herbs like Chaste tree aka Vitex have been shown to improve progesterone levels in cycling women and stress management is another critical component to treating low progestogen since high cortisol can decrease progesterone production.

Immunological causes

During pregnancy your body has to change its typical immune system response in order to stop the body from rejecting the fetus. Your immune system weakens during pregnancy to prevent it from attacking your baby as a foreign body, which is why pregnant women are more susceptible to colds & flus. Research shows that abnormally high in antibodies and NK cells can both increase your odds of miscarriage.

• Testing: CBC + WBC to see an overview of immune function, vitamin D (important for immune regulation) and screening for autoimmune diseases like Hashimoto’s, RA & Grave’s. Specialized testing for HLA incompatibility, anti-paternal antibodies, and NK cells may be accessed through your fertility clinic.
• Signs: Women with pre-existing autoimmune disease often have fatigue, joint pain, flu-like symptoms and highly active immune systems (meaning they are always sick, OR never sick!).
• Treatment: conventional treatment options include the following, & their prescription will be based on your fertility clinic’s assessment of your immune health; steroids, intravenous immunoglobulin (IVIg), tumour necrosis factor (TNF) blocking agents or anticoagulants. Your naturopathic doctor can help you address dietary & lifestyle factors, as well as prescribe herbs that can help balance out an over-active immune system.

Dysbiosis

Dysbiosis refers to an imbalance between the types of bacteria present in a pregnant woman’s gut & vagina. One common cause of miscarriage is infection caused by dysbiosis in your vaginal microbiome. A healthy vaginal microbiome is typically dominated by a type of good bacteria called Lactobacillus, which protects you against infections that can weaken the cervix or potentially harm your developing baby. Newer research is also making links between a compromised gut microbiome & leaky gut and miscarriage. In one study, women with recurrent pregnancy loss had higher prevalence of undiagnosed gut disorders & increased gut permeability which allows for the passage of immune triggers from bacteria in the gut to impact endometrial tissue health.

• Testing: a cervical swab can help you assess which types of bacteria are living in the vaginal microbiome. Zonulin testing or PCR stool testing (aka GI MAPs) can help us assess for gut lining health and determine the quality of bacteria living your GI system.
• Signs: women with vaginal dysbiosis often experience recurrent yeast infections or bacterial vaginosis, or may notice changes to discharge or vaginal odour. However, there’s a type of bacteria called mycoplasma genitalium which has been linked to miscarriage and typically has no symptoms. Gut dysbiosis often presents with loose stools, constipation, gas, bloating or digestive pain, it can also show up as rashes or acne.
• Treatment: targeted oral antibiotics, followed by vaginal probiotics has been shown to be an effective treatment for vaginal dysbiosis-caused miscarriage. Oral probiotic or customized eradication & gut repopulation protocols administered by your naturopathic doctor can help address gut dysbiosis.

If have more questions, or if you’d like more personalized support with your wholistic fertility plan you can book online with Dr. Sarah here.

*Note: online services provided by Dr. Sarah are only available to patients living in Ontario.

Disclaimer; this information is not intended as a substitute for the advice provided by your Naturopathic doctor or primary care physician. Do not use the information in this document for diagnosing or treating a health problem or disease. Always speak with your Naturopathic doctor before taking any medication or nutritional or herbal or using any treatment for a health problem. If you have or suspect that you have a medical problem, contact your health care provider promptly. Do not disregard professional medical advice or delay in seeking professional advice because of something you have read online.