This post discusses sensitive topics such as miscarriage, stillbirth, and infertility. Please protect your mental health and exercise caution in reading if these topics are triggering to you.
Growing a family is not always easy for everyone, despite what the media or the ever expanding families in your social media feed often portray. While 1 in 8 couples will struggle with infertility (unable to conceive after 1 year of regular unprotected sex), it’s estimated that 1 in 4 known pregnancies nowadays will end in loss (no live baby to bring home). These losses can happen at varying stages of pregnancy and that can also give us indication of what could have possibly contributed to the loss.
I want to preface this by saying that miscarriage is NOT the fault of any woman. Neither is infertility.
Even if you discover that you do have contributing factors through testing, it does NOT make the miscarriage your fault. Also, miscarriage is NOTHING to be ashamed of. It’s not a moral failing, nor is it an indication that you won’t make a good mom.
It’s also not just “no big deal”. However you feel about your miscarriage is COMPLETELY valid. Grief is real and valid even if you only knew you were pregnant for 1 day or if you were pregnant for almost 5 months. It’s all valid.
My goal in writing this post is to bring awareness and empowerment to women who have lost a pregnancy. Many of them want to find answers or understand what is possibly in their control. This is normal and also can be a helpful part of the grief process, to have some clarity and closure. Even if the result is that we just don’t really know why the miscarriage happened, it can be helpful and healing to know you explored your options.
If you’re reading this, and you have lost a pregnancy or baby before, I want you to know that I see you. Your grief is valid. Your baby and pregnancy is valid. And your desire to explore every option you have is also valid. Understanding your health before you conceive can help set your baby up for optimal health and development and also help you become as healthy as possible if you discover some areas of your health that could use more support.
My other goal in writing this post is to help women who are planning pregnancies who may have concerns about their fertility and the viability of their future pregnancies. Perhaps you are that woman. Maybe you know people who have struggled on their motherhood/parenthood journey and you’re worried that those struggles may be in your future too. You like to plan and want to be as prepared as possible. I commend you for seeking to get in the best health possible before pregnancy.
That isn’t something that’s always culturally encouraged or talked about, but I want you to know that it has a tremendous impact on the future health of your baby and it does matter. Maybe you told your doctor to remove your birth control and asked them what to do to prepare for pregnancy, and they didn’t offer many suggestions. Maybe you intuitively know there is more you can do. If that’s you, then you’re in the right place and you can read on to find more ways to take control of your health.
Many women are also understandably nervous to get pregnant again. For some it may be quick and easy to do so and have a healthy pregnancy. But still again, for some, it’s not easy and they may experience multiple losses. I want to empower all women to know their options for testing and optimizing their health and chances of a healthy baby before they try again and while they are newly pregnant to know they are doing everything in their power.
Some testing and optimizing might not make the complete difference between live birth or miscarriage, but can actually help improve baby’s chances at a healthy life, so exploration and optimizing is always useful in my view.
Miscarriage vs. Stillbirth Defined
In the US definition, a miscarriage is any pregnancy loss that occurs before the 20th week of gestation. Weeks of pregnancy are counted from the date of a woman’s last menstruation, so there are about 2 weeks when you’re not actually pregnant, but those are weeks 1 and 2 of your pregnancy. Most women don’t know they are pregnant until they are about 4 weeks along, or about 2 weeks after ovulation and fertilization, and once they now have a missed period.
In the US, a stillbirth is a loss of a baby after 20 weeks of gestation. This affects about less than 1 percent of all pregnancies. The rate also varies based on the mother’s ethnicity. Racial discrimination and access to maternal and prenatal care for all economic levels is a major concern in the US and needs to be addressed.
Whenever the loss occurred, the result is usually equally devastating emotionally for the parents, and can have long lasting emotional impacts, more typically seen in the mom. For this post, we will be discussing the possible causes of miscarriages and not stillbirth. While there may be some overlap of factors, we’ll focus on miscarriage.
Odds of Miscarriage
It’s estimated that 1 out of every 4 known pregnancies ends in miscarriage. This includes pregnancies that the woman only discovered using an at home pregnancy test and those that are clinical pregnancies. A clinical pregnancy is one where an ultrasound has confirmed the presence of a gestational sac, at the very least.
The gestational sac will be visible on a vaginal ultrasound beginning around 5 weeks of pregnancy, which is usually before a heartbeat, egg yolk, or embryo can be seen. The risk of miscarriage continues to drop once a strong heartbeat has been detected via ultrasound and every week after that where a strong heartbeat is still present.
Many studies have attempted to estimate the risks of miscarriage by weeks gestation, and while none may be perfectly accurate, I think this chart is probably pretty close. You can also input some personal data to adjust the risk to you personally, since risks increase with certain factors.
Where Do We Go From Here?
For many women, after having one miscarriage, their doctors will tell them to wait 1-3 menstrual cycles and try to conceive again. There may be some minimal testing, but when the results appear negative, doctors may not offer many more solutions or avenues to explore. Many doctors won’t even dig into possible causes until a woman has had 2-3 consecutive miscarriages. At that point, it’s termed recurrent miscarriage and they will begin to do some testing.
Doctors do this because there is a great likelihood that a woman who had a miscarriage will soon go on to conceive and carry a healthy child, which is of course amazing news!
BUT that’s just not always the case. Whether there is a great likelihood of a successful subsequent pregnancy or not, I believe women should be given options to make informed decisions and gather as much information as they want following a miscarriage. Some women will struggle with difficulty conceiving and some will have additional miscarriages; whether consecutively on in between other live births.
Some women also try to conceive for a long time before finally getting pregnant, only to miscarry. This is devastating and there may be underlying factors that contribute to the difficulty conceiving AND the miscarriage, that if addressed properly, can boost a woman’s ability to conceive faster and have a healthy baby.
Some women also are unaware of their underlying conditions, which can influence their experience postpartum. For example, women with elevated thyroid antibodies prior to and during pregnancy may have a greater risk of postpartum thyroiditis which can lead to hypothyroidism, fatigue, thinning hair, feeling cold, low milk supply, depression, anxiety, and more unpleasant symptoms.
While postpartum is by no means a walk in the park and fatigue is common from lack of sleep, we certainly don’t want to exacerbate any of the physical challenges of adjusting to postpartum life. Knowing your underlying health factors going into pregnancy and postpartum can help you create a plan to support your optimal health so you and baby can thrive as much as possible in this special time.
Basically, I’m a big believer and advocate in all women testing, questioning, and understanding their unique health picture and possible underlying factors so they can increase their own health and well being, reduce the risk of miscarriage, have the healthiest pregnancy and baby possible, and be prepared with tools to help them have optimal health during the challenging postpartum phase.
If you’ve experienced even 1 loss, it is gut wrenching to imagine having to have 2-3 before doctors will take your concerns seriously. I believe women deserve better. There are many possible causes of miscarriage and knowing that you’re exploring all possible avenues can bring healing and closure, and be extremely useful in addressing for future pregnancies to ensure viability.
Before we get into possible causes, let’s examine the different types of miscarriage. The type of miscarriage can help identify clues as to possible underlying concerns.
This refers to a miscarriage where the woman’s body naturally lets the pregnancy go without the use of medication or surgical procedures. This can result in being complete (all the tissue was expelled) or incomplete (some tissue remains in the woman) at which point surgery to remove the tissue may be required.
This refers to the discovery of the miscarriage, usually via ultrasound, before the woman’s body has naturally miscarried. It’s usually discovered via routine ultrasound where a baby is measuring behind in size, or a heartbeat is not detected at a week of gestation where it should be detectable. This could happen at the first dating ultrasound around 8-10 weeks gestations, or it could happen at a 2nd ultrasound even after a 1st (earlier) ultrasound showed a healthy, on track baby and heartbeat.
This refers to a conception that stopped developing shortly after fertilization or implantation. It’s also referred to as an anembryonic pregnancy because no embryo developed inside the gestational sac. It’s usually suspected that there was some abnormality with the egg or the sperm, hence the term blighted ovum (meaning blighted egg). This may be detected via routine ultrasound and is considered a type of missed miscarriage in that situation.
The gestational sac can continue to grow for weeks and HCG levels can rise, so a woman won’t suspect anything until ultrasound reveals the pregnancy is not viable. It can also end in a spontaneous miscarriage once the body realizes the pregnancy is not viable and if it was never seen on an ultrasound, a woman may not know it was a blighted ovum vs. a baby that did develop more but then stopped. This can be waited out and a woman may naturally miscarry, or it can be induced via medication, or removed via D&C procedure.
It’s believed that up to half of all miscarriages are the result of a blighted ovum. Some women may naturally miscarry and never know for sure that it was a blighted ovum due to not seeing it on ultrasound.
This is a type of very early pregnancy loss where an egg is fertilized but never completely implants into the lining of the uterus. This usually occurs around week 4-5 of the pregnancy. A woman may have a missed period and receive a positive pregnancy test that gets lighter in color on subsequent days of testing, instead of darker as HCG levels should increase. A spontaneous miscarriage would then occur shortly thereafter around a week after the missed period and may be heavier than a usual period.
This is when a fertilized egg implants and grows somewhere outside the uterus. This could be implanting in a fallopian tube, ovary, abdominal cavity, or cervix. Hence it is also called an extrauterine pregnancy (as opposed to an INTRAuterine pregnancy). An embryo cannot develop properly in any of these locations and the pregnancy is not viable. It also causes danger to the mother if left untreated.
For example, if implantation occurred in a fallopian tube (the most common ectopic pregnancy), there is danger of the tube rupturing as the baby grows and develops and can be life threatening to the mom if not removed. This sometimes results in the surgical removal of the pregnancy and in some cases, removal of one of the woman’s tubes if damage has occurred.
There are other types of pregnancy loss, including molar pregnancy, but these listed above provide some context for discussing some of the possible reasons for miscarriage.
Use of the Word Abortion in Medical Literature/Settings
I also wanted to note something in the medical community that can cause confusion and hurt for women who experience miscarriage. In medical literature, spontaneous and missed miscarriages are referred to as spontaneous and missed abortions. This is used in reference to the natural way that the baby’s life ended. When a pregnancy and baby is very much wanted, hearing or reading this term in the doctor’s office, on hospital bills, or insurance claims can be traumatizing and insulting.
Understand that it is not a reference to the intentional termination of a pregnancy, but a term used in medical literature and medical settings to describe the unintentional ending of a pregnancy. Some doctors are more emotionally sensitive and may verbally use the term “missed AB” or “spontaneous AB” when speaking with other medical professionals, such as scheduling a D&C with the hospital.
I do want to iterate that a loss is a loss is a loss. Having an early miscarriage doesn’t make your pregnancy, child, or grief any less valid and whatever the type of loss, it is never your fault <3.
I am passionate about helping women reduce their risk of miscarriage because it is a woman’s health issue. But more than that, it’s a mental health issue and and can become an intergenerational issue. Women who miscarry are more at risk for anxiety and depression even after the birth of a healthy child. Children and families can be negatively affected by moms with untreated anxiety and depression, so helping women physically, emotionally, and mentally through miscarriage, even for years after, can have far reaching impacts on their health and family’s health.
I just want women to have confidence that they are doing all they can to have the best chances of a healthy pregnancy. That can bring peace and acceptance as we ride the rollercoaster of family building, whatever comes our way.
Some miscarriage is probably always going to exist, even in a perfectly healthy world. That’s because freak incidents occur and in this case, chromosomes aren’t maybe always going to behave and divide properly, even when they have everything they need.
But, I believe that if we were more proactive as a society in helping women understand what health makers can reduce the risk of miscarriage and helping empower them through preconception care, we can help reduce the risk and number of miscarriages and bring more healthy babies home who leave us too soon.
Possible Causes of Miscarriage and How to Address Them
1. The most common reason for miscarriage is chromosomal abnormalities. This can be either extra or missing chromosomes.
An embryo gets one set of chromosomes from the ovum that mom produced and one set of chromosomes from the sperm that dad produced (23 + 23 = 46!). It’s often thought that the ovum caused these abnormalities, but it’s also possible that an abnormal sperm contributed to the chromosomal abnormalities. Both mom and dad’s health are important for baby’s health.
The female body does have some weeding out mechanisms (like certain properties of cervical mucus) to only allow the most robust and “perfect” sperm through to be near the egg to fertilize it, so that may contribute to the belief that it was an error in the egg’s chromosomes that most likely caused the abnormality. But it’s possible to be either one.
When a woman is growing inside her own mother’s womb as a baby, she develops all the eggs she will ever have. This is estimated to be about 6 to 7 million oocytes between 16 and 20 weeks gestation, and drops to about 1-2 million when she is born. As the baby girl grows and ages, she has about 300,000-400,000 at the time of puberty.
Each month after menarche, multiples eggs are recruited in the body and develop to ovulate with typically one maturing faster and thus being the one to be ovulated. The other eggs that partially matured are absorbed back into the body. The remaining gametes that weren’t recruited to become eggs and to be ovulated remain in a suspended state waiting for their turn.
About 3-4 months prior to an egg being ovulated, the eggs begin to undergo a “final” maturation process. This process involves cell division of meiosis, where a female sex cell divides to become the ovum with the right amount of chromosomes (23).
During this process, it’s possible for that process to not go perfectly and the egg can end up with a number of chromosomes other than 23. This is called aneuploidy. This process relies on healthy mitochondria which are damaged from oxidative stress. Most errors thus occur in a small window before ovulation because oxidative stress actually damaged the cell’s mitochondria.
For help understanding oxidative stress, the rusting of metals exposed to oxygen and moisture is an example of oxidation. Oxidation is also why food browns when exposed to oxygen after being cut open, like with apples and avocados.
The narrative we often hear as well is that egg quality just declines with age and there is nothing we can do about it, except maybe freeze our eggs when we’re young. While that option does exist, it’s not the only option and probably not even a feasible option for most women. The truth is that most of the chromosomal abnormalities don’t develop slowly as we age, but occur right before ovulation during this cell division process. It’s also true that women of the same age can have completely different egg quality levels.
What a Doctor May Tell You: “Your miscarriage was likely caused by chromosomal abnormalities that randomly occurred. You can try again in 1-3 menstrual cycles.”
Vs. What You Can Actually Do: Your miscarriage was still likely caused by chromosomal abnormalities that spontaneously happened. Meaning you didn’t sit there and tell your brain to mess up in meiosis, just like you don’t control if your heart beats or not. It’s just subconscious, a process that happens without our direct impact. BUT that’s not to say that our choices can’t REDUCE the risk of eggs developing abnormally, because they definitely can! Can they completely eliminate abnormalities? No, probably not, because there may always be some statistical amount that will occur due to true random chance, BUT we can do so much to give our bodies and eggs all the tools they need to thrive properly.
These abnormal cell divisions happen more frequently as we age and when exposed to certain environmental toxins, both which result in more oxidative stress in our bodies. With targeted lifestyle and diet changes, we can however help improve egg quality at any age.
The process of sperm cell maturation also takes approximately 3 months, where male sex cells undergo mitosis and meiosis to have the right number of chromosomes in the sperm. Men can also benefit from lifestyle and diet changes that help provide all the nutrients and energy that these cells need to properly complete this maturation. It’s beneficial for both partners to start a healthy regime about 3-4 months before they plan to try to conceive.
Steps to Take to Improve Egg and Sperm Quality and Reduce the Risk of Chromosomal Abnormalities:
- Increase the amount of antioxidants obtained via diet to combat oxidative stress in the body (think fresh fruits and vegetables).
- Reduce or stop activities that are known to increase oxidative stress
- Stop smoking and any illegal drugs
- Reduce or stop alcohol use
- Remove trans fat from diet
- Reduce high glucose foods like refined flour products, high sugar foods, and other processed foods
- Increase fiber intake (again, fruits and vegetables are great for this)
- Exercise to boost mitochondrial function (find exercises you actually like–punishing yourself is not going to be good for your health)
- Reduce toxins in your home and environment
- Eat organic food/wash produce to reduce pesticide exposure
- Avoid endocrine disrupters like BPA, parabens, and phthalates
- Purchase a water purifier to reduce the specific contaminants in your location. Use this tool to learn more about the water quality of your area (US only). This is a good test if you want to personally test your water supply in your home.
- Get adequate sleep (7-9 hours)
- Consider targeted supplementation with a practitioner to help with certain factors like age, autoimmunity, PCOS, etc.
It Starts With the Egg by Rebecca Fett is a great resource in better understanding egg quality and the science behind how to improve it. The topics in the book are also all topics I cover with clients and help them determine a bio-individually appropriate lifestyle, diet, and professional grade supplement plan to improve their chances at healthy eggs.
Depending on age and other factors, some good supplements to consider are CoQ10 in the ubiquinol form, melatonin (for older women especially), diet rich in whole foods, DHEA, methylfolate and/or folinic acid, B6, B12, and magnesium. It’s always important to work with someone to get the right kind and dose for you, especially with DHEA since it’s a hormone and should not be taken without working with a practitioner.
It’s estimated that chromosomal abnormalities are the cause of more miscarriages than all other known reasons combined. That can also largely be attributed to the number of miscarriages that are estimated to occur very very shortly after fertilization and before a women even knows she is pregnant.
It’s also more likely as we age that egg maturation will result in chromosomal abnormalities in eggs. This can be due to natural decrease in antioxidants as we age including melatonin levels. This doesn’t mean healthy pregnancies and babies are impossible when we’re older, but rather that we can make an even more concerted effort to nourish our bodies and cells in an intentional manner leading up to trying to conceive. Regardless of age, ensuring large amounts of antioxidants in diet by eating lots of vegetables and antioxidant rich fruits like berries, helps to combat that oxidative stress that causes problems.
This information is in no way shared to shame anyone if they had a miscarriage that their doctor believed to be or confirmed to be due to chromosomal abnormalities. Most sex education, family planning, or health courses don’t offer this info and it’s not usually brought to our attention until after a fertility or miscarriage struggle.
The “pill for every ill” model of conventional medicine also tends to favor medications, or promotes a doom and gloom look at age and fertility correlation without also sharing the incredibly empowering knowledge that we can have an influence on these outcomes as it relates to egg quality and sperm quality.
I’m sure some doctors also would love to share info with their patients but maybe don’t have a lot of time to do so, or the majority of their patient experience has been that it’s hard to get people to make lifestyle changes so they stop making those recommendations and stop emphasizing their importance.
In my ideal world, women and men would be taught these things from a younger age or in their 20s, as part of marriage prep courses, or even when they go into a doctor’s office and let the doctor know they want to plan a pregnancy soon. I hope that the norms of society change where instead of planning weddings for months and years and preconception prep consists of just stopping birth control, there would be a societal norm to focus inward and really nourish men and women who are planning to grow their family in the next 6 months to a year. We owe it to our children and the next generation to do our part to make sure they have the best health possible.
Having a miscarriage that’s suspected to be due to chromosomal abnormalities does not mean that it wasn’t meant to be, that this happened for a reason, or that this is your fault. What I hope you walk away with though, is the knowledge that you CAN make diet and lifestyle changes (and even targeted supplementation) that can improve the quality of your eggs and reduce your chance of miscarriage, no matter how old you are.
2. Underactive Thyroid
The thyroid is a vital part of our endocrine system. It is a butterfly shaped gland located behind our Adam’s apples in our throat/neck area. It produces hormones that control our metabolism, weight, body temperature, skin, energy to organs, impacts the production of other hormones including sex hormones, and more.
The hypothalamus in our brain monitors the situation in our body and sends signals to our pituitary regarding how much thyroid hormone we need. The pituitary then releases another hormone which prompts the thyroid to increase activity and thus get more thyroid hormones for our body’s needs. The pituitary also responds to thyroid hormone levels in the blood to decide how much to prompt the thyroid to produce. Thus, the thyroid is part of an important system called the hypothalamic-pituitary-thyroid axis (or HPT axis for short).
The thyroid in a healthy individual produces 5 hormones:
T4- Thyroxine: Called T4 because its chemical structure is 1 thyroglobulin (protein that is a modification of the tyrosine amino acid) and 4 iodine atoms
T3- Triiodothyronine: Called T3 because it’s chemical structure is 1 thyroglobulin and 3 iodine atoms
T2– 1 Thyroglobulin + 2 iodine atoms: For more information about T2 visit here
T1– 1 Thyroglobulin + 1 iodine atom: not much is known about the direct function T1 has in the body and it is believed to be “inactive”
Calcitonin– Thyroid hormone that regulates calcium in the body, in conjunction with hormones produced by the parathyroid (another gland behind the thyroid)
T4 is produced in the greatest abundance, and then a little T3 is made by the thyroid as well. Most T3 is actually made by a process called deiodinization where a T4 has an iodine removed. This process occurs mostly in other body organs, like the gut, liver, and spleen and requires nutrients like zinc and selenium to make this conversion.
When Your Thyroid Doesn’t Produce Enough Hormones
Underactive thyroid or hypothyroidism is the most common thyroid condition. This is when the thyroid gland no longer produces adequate amounts of thyroid hormones. In the developed world, this is caused predominantly by an autoimmune condition known as Hashimoto’s where a woman’s immune system has identified parts of her thyroid tissue and thus produces antibodies to it and attacks and destroys the tissue. Over time, this results in an underproduction of thyroid hormone. In other parts of the world, low functioning thyroid is more commonly due to an iodine deficiency since iodine molecules directly make up thyroid hormones.
Some thyroid stats from American Thyroid Association:
- An estimated 20 million Americans have some form of thyroid disease
- Up to 60 percent are unaware of their condition
- Women are 5-8 times MORE likely than men to have thyroid problems
- Untreated hypothyroidism increases risk for miscarriage and severe developmental problems in children
Symptoms of Low Thyroid and Testing
Symptoms of low thyroid hormone and function include weight gain, hair loss, always feeling cold, poor memory, high cholesterol, fatigue, lethargy, muscle aches, eye and face swelling, dark under-eye circles, irregular or heavy periods, depression, coarse hair, constipation, and more. There are also women who do not experience regular symptoms and therefore do not think to ask their doctor for testing when they do in fact have a thyroid condition.
When testing for thyroid function, it’s important to test all the markers to get a good picture of what’s going on. Many doctors are known to only order a TSH test for thyroid stimulating hormone, but that is actually a pituitary hormone and isn’t telling us about the levels of actual thyroid hormones in our body.
A Full Thyroid Panel for Hypothyroidism Consists of the Following:
TSH: Thyroid Stimulating Hormone
Free T4 or FT4: Free Thyroxine hormone
Free T3 or FT3: Free Thyronine hormone
Reverse T3: Reverse T3 is an inactivated form of T4.
TPO Antibodies: Thyroid Peroxidase Antibodies
TG Antibodies: Thyroglobulin Antibodies
You can have one or both types of these antibodies elevated on blood tests. Having either one or the other indicates an autoimmune attack on the thyroid known as Hashimoto’s. It’s more common to have elevated TPO antibodies but many people have both, and some people even have just elevated TG antibodies.
If you discovered you had only a sluggish thyroid and no autoimmunity, you might approach improving thyroid function with targeted nutritional support such as iodine, selenium, and removing toxins that hinder the thyroid.
If you discover that you instead DO have an autoimmune attack that is causing low thyroid function, you may also do the same things as above but also approach it differently and work on gut health to improve the immune system, removing foods from your diet you are sensitive to, as well as targeted nutritional support for optimal thyroid function. There can be other root causes to this immune system dysfunction, such as infections, parasites, chronic stress, trauma, mold exposure, and more. Just like we’re all unique, our underlying root causes can be unique too.
If the damage has gone on for so long, it’s important that you discuss thyroid replacement prescriptions with your doctor, especially if you are trying to conceive or pregnant. Due to the lack of widespread screening of woman during preconception check-ups, it’s typical for damage to be so advanced and have been ongoing for years before the issue is detected via bloodwork.
Working on healing these issues can take months and years to get to the root cause, and if you’re pregnant or could be pregnant, it’s critical that you and baby get the thyroid hormones that baby especially needs for proper development in utero. Untreated low thyroid in pregnancy does cause developmental issues in babies. Babies in utero do not have their own functioning thyroid until about 12 weeks gestation, but it’s not fully functioning until about 18-20 weeks.
There are some thyroid experts that believe once damage has been initiated, it’s impossible to completely heal and restore optimal functioning, so a combination of T4 and T3 prescriptions or natural desiccated thyroid (NDT) prescriptions can be used to get optimal thyroid levels for better quality of life, reduction in hypothyroid symptoms, improved fertility, and to get optimal thyroid levels to baby.
For even more in-depth info on thyroid, check out my upcoming in-depth article which also details thyroid hormone replacement options to be aware of when talking to your doctor, if thyroid glands can be healed, and so much more. Those subscribed to the Full and Wholly Nourished newsletter will be first to be notified when the article is live.
3. Low Progesterone
Progesterone is the pro-gestate hormone produced by the corpus luteum that is left behind in the ovary when the egg is ovulated. It’s the hormone that predominates the 2nd half of the menstrual cycle since it’s role is to prepare the uterus and body for implantation of a fertilized egg.
Progesterone thickens the lining of the uterus so that it can nourish the implanted fertilized egg. The presence of progesterone in the blood over a certain threshold is used to determine if a woman is indeed ovulating in the first place.
Low progesterone can make it difficult for women to get pregnant in the first place, even if the egg is being fertilized. Signs and symptoms of low progesterone include short luteal phase, spotting before period starts, brown blood before period starts or period bleeding ending in brown blood.
A simple blood draw for progesterone can be done around 7 days after a woman’s ovulation to see her peak value. Optimally, this would be around 15 ng/ml or higher, but above 3 ng/ml indicates the woman ovulated (albeit considered a “weak” ovulation) and above 10 ng/ml is enough to sustain a pregnancy.
It’s also possible to do multiple blood draws including 3 dpo (days post ovulation), 5 dpo, 7 dpo, 9, dpo, and 11 dpo to see the curve of progesterone production. This may not be the most practical testing, but could show if progesterone production is peaking too early or too late and may be contributing to difficulty achieving a pregnancy.
There is also an at-home progesterone testing option called Proov. This test measures urine amounts of a progesterone metabolite to confirm ovulation and thus the presence of enough progesterone in your body. It does not confirm a quantitative amount though, so getting a blood draw would still be more specific information.
The Production of Progesterone
In the beginning of a pregnancy, progesterone is produced in the ovaries by the corpus luteum. Rising HCG levels in pregnancy encourage the corpus luteum to make higher amounts of progesterone. Eventually, around 10-12 weeks of gestation, the placenta will become the main producer of progesterone.
When eggs are being recruited to ovulate and burst from a woman’s ovaries, multiple follicles develop, each with an egg inside. One of these eggs grows more rapidly than the other eggs and becomes the dominant follicle. This is the egg that responds to the hormonal surge of LH and bursts from the follicle and ovary and into the fallopian tube. In other words, you’ve ovulated that egg!
Now that follicle that “won” the ovulation race and evicted it’s egg, crumples in on itself and becomes a sort of shriveled mass that still has an important role. As the corpus luteum, it produces progesterone. Progesterone is what thickens the lining of the uterus so if the egg is fertilized, it can go cozy into the uterine lining and keep on growing.
In functional and integrative medicine, the approach goes deeper than just “low progesterone”. The ability of the corpus luteum to produce the right amount of progesterone can point to inadequate follicle or corpus luteum development. This is influenced by egg quality, thyroid disorders, insulin resistance, inflammation, and even nutrient deficiencies (more on those later).
Thus, ways to naturally increase progesterone include optimizing thyroid function and thyroid hormone levels, maintaining healthy weight, regular moderate exercise, consuming healthy carbohydrates with plenty of protein and fats, nutrient dense diet to correct any nutrient deficiencies plus possible targeted supplementation, eating foods to reduce excess estrogen, and managing and reducing stress.
Progesterone supplementation is also an option, especially if you are already pregnant and your progesterone is on the lower end.
Options for Progesterone Supplementation
- Over the counter creams–These are the least effective since absorption is somewhat unpredictable.
- Vaginal suppositories–These are made by a special pharmacy called a compounding pharmacy and inserted as close as possible to the cervix. The idea is that the progesterone is absorbed and delivered to where it is needed the most and it isn’t broken down first by the liver. A woman may be prescribed to insert these suppositories every morning and night, or only at night, depending on her levels and her doctor’s approach.
- Progesterone pills–Another prescription given by your doctor. While these are typically designed to be taken orally, some women are also given these pills and told to use them vaginally by their doctor.
- Progesterone in Oil or PIO shots intramuscularly–This is the kind usually prescribed in extreme cases since it’s the most effective at quickly raising progesterone levels and this is typical standard protocol for IVF cycles.
Once you have been confirmed pregnant by a home pregnancy test, you can request a progesterone test, especially if you have a history of loss and/or infertility or risk factors for low progesterone. Supplementing with progesterone can help maintain an otherwise viable pregnancy that was at risk of loss due to low progesterone. You can also request progesterone testing throughout the first trimester at regular intervals if your history warrants it. If you want it for peace of mind, you can also find a self order lab test and order it yourself.
As for what levels should be, a 2017 study found that a minimum of 25 ng/ml progesterone blood serum levels was recommended for women to maintain in the 1st trimester to avoid miscarriage in those with a history of miscarriage and/or infertility.
OBGYNS trained in NaPro technology (Natural Reproductive specialists trained by the Saint Paul VI Institute for the Study of Human Reproduction) utilize this chart to measure if a woman’s levels of progesterone are good for her point in pregnancy and adjust accordingly via supplementation and prescription. The solid line represents the average and the dotted lines represent 1 standard deviation in each direction.
NaPro doctors prescribe more progesterone support for women with levels in Zone 1 since the higher the zone, the better the level of progesterone.
4. MTHFR Gene Variation
The advent of genetic testing and better understanding of the human genome has led to many discoveries about genetics and common variants in the population. One variant that impacts miscarriage risk is having a genetic single nucleotide polymorphism (or genetic SNP for short) that effects the enzyme known as methylenetetrahydrofolate reductase or MTHFR for short.
This enzyme is involved in the processing of folate and the synthetic version known as folic acid. When a woman has one or more of the variants, her ability to process folic acid is reduced and an excess of folic acid in her body can inhibit the utilization of folate. This can effectively create a folate deficiency and high levels of homocysteine in the blood which has been linked to neural tube defects in a growing embryo or fetus, increased risk for miscarriage, recurrent miscarriage and spina bifida. To learn more in depth about MTHFR, see the work of Dr. Ben Lynch.
Many women and men (an estimated 30-60% of the population) have a heterozygous (meaning only inherited one copy from one parent) or homozygous variant (meaning they inherited a copy from both parents) in this gene. Homozygous for MTHFR is linked to an even greater reduction of this enzyme than the heterozygous version.
To determine if you have this genetic SNP, you can request this test from your doctor, but it may not be covered by insurance. You can also get this information by doing genetic testing through companies like MaxGen and their Functional Panel which will give you info about MTHFR plus other genetic info for you.
However, the recommendation whether you have it or not is going to be overall beneficial to your health so you can save the money and just implement steps such as listed below, unless you really want to know for sure. You might really want to know if you have recurrent miscarriage or have siblings or parents who had recurrent miscarriage as well. MTHFR is also linked to elevated oxidative stress, which we know can contribute to chromosomal abnormalities in developing eggs and sperm and increase the risk of miscarriage.
What To Do If You Have MTHFR or Suspect You Might:
- Avoid folic acid, the synthetic form of naturally occurring folate.
- This is found in fortified foods such as flours, crackers, cookies, cereals, and other packaged food, as well as most drug store prenatals.
- Take a prenatal with natural folate versions, NOT folic acid. For more on what those types are called, download my FREE guide to prenatal nutrients.
- Eat sources of natural folate in your diet: leafy greens, liver, legumes, asparagus, citrus, brussels sprouts, etc.
- Get enough Vitamin B12 in diet and supplements (if needed). You can get Vitamin B12 labs drawn to see how your levels are.
- Support your detox pathways (sweat and poop regularly)
You can also read my other post all about MTHFR, fertility, and miscarriage which also highlights the impact that MTHFR gene variations have on male fertility.
5. Untreated Clotting Disorders
Factor V Lieden
Factor V Lieden is a genetic condition that makes blood more prone to abnormal clotting. Clotting in blood can cause miscarriage because it can disrupt placental and embryo development which relies on steady blood source for nutrients. Studies have shown that women with Factor V Lieden have lower birth rates and can be prone to recurrent early miscarriage.
Your doctor can test for this if you’ve had abnormal clotting or have a family history of abnormal clotting. Your family members may also know or be aware of a family history of this.
As with most genetic mutations, you inherit a gene from both mom and dad so you can be heterozygous for the trait (only got one copy from one parent) or you can be homozygous for the trait (both parents gave you a copy). The susceptibility to blood clotting may be worse in those who are homozygous for Factor V Lieden (FVL), but this is rarer.
It’s estimated only 5% of the population has FVL, either heterozygous or homozygous. Those with Northern European ancestry are more at risk of having the mutation and the rate in some Northern European countries may be about 10-15% of the population. It’s less likely to occur for those with Native American or African-American heritage.
Antiphospholipid syndrome (APS) is another condition where the immune system makes some costly mistakes. By creating antibodies, its makes it more likely that your blood will clot and cause miscarriage and stillbirth if baby’s blood supply and nutrition is cut off. This is not strictly genetically inherited, since it develops over time in the body.
Only 2-4% of the general population has antiphospholipid antibodies and it’s considered a factor for about 15% of women who have recurrent miscarriage. It can cause late miscarriage (after 12-14 weeks) as well as stillbirth, and it could have role in early miscarriage by interfering with the egg’s implantation into the uterus.
Early knowledge in pregnancy of APS is important to create a treatment plan with your doctor to reduce the risks associated.
There may be more conditions and even medications that increase the risk of blood clots. You can request testing from your doctor for these conditions, especially if you know you have a family history of these issues.
Blood thinners may be prescribed as a preventative measure in your future pregnancies to prevent clotting from happening. When blood thinning agents are prescribed by your doctor, they may also counsel you on how much Omega-3s to take. Omega-3s also have a naturally blood thinning ability, but blood that doesn’t clot can also be dangerous during injury due to causing too much blood loss, which is also not safe for mom and baby.
MTHFR can also play a role in increasing the risk for blood clots since high levels of homocysteine in the blood are a risk factor for hypercoagulability of blood, or the tendency to clot easily.
6. Uncontrolled Diabetes
Type I Diabetes occurs when your pancreas no longer produces insulin, usually because of an autoimmune attack on the cells of the pancreas that produce this hormone.
Type II diabetes occurs when your pancreas produces enough insulin, but your cells have become resistant to it, so instead of letting the glucose into your cells, your blood glucose levels will stay elevated for longer.
Screening for diabetes and pre-diabetes can be a simple part of preconception check-up or blood tests run following a loss. To get a good understanding of your diabetes risk and metabolic health, you can request a fasting blood glucose, A1C, and fasting insulin level test.
I recommend this for all clients because it’s an extremely important marker for overall metabolic health and insulin resistance and blood sugar issues are critical for egg quality. Even getting mildly elevated issues that are not in the diabetic range in check can help improve egg quality and possibly pregnancy outcomes, including reducing the risk of developing gestational diabetes.
Some symptoms to look out for that can indicate checking in on these levels is a good idea include the following:
- sugar and or carbohydrate cravings
- weight gain around the abdomen
- getting light headed, hangry, or fatigued before your next meal
- sleepiness after a meal
- difficulty losing weight (can also be linked to thyroid)
- frequent snacking and cravings for snacks
- frequent urination
- frequent urination in the middle of the night
For fasting blood glucose, most lab ranges go up to 100 mg/dL as normal, but optimal is closer to 85 mg/dL, based on Functional Medicine levels.
Fasting insulin lab ranges also go up to 10 uIU/mL, but under 5 uIU/mL is optimal and under 7 uIU/mL is good, again, based on Functional Medicine levels.
Diet and lifestyle changes like balancing macronutrients at meals, choosing the right kinds of carbohydrates, eating more fat and protein, reducing stress, and moderate physical activity can be helpful ways to improve insulin sensitivity, reduce the risk of developing diabetes, and improve health prior to conception.
Even if a woman (or her partner) has no risk factors for diabetes, it’s beneficial to have these tests run to get a baseline knowledge of metabolic health for both parents. Being undetected pre-diabetic prior to pregnancy increases the chances of developing gestational diabetes and increases the chance of certain pregnancy complications.
Better to know and work to optimize these health markers as much as possible before conceiving or at least be informed about them during early pregnancy to make a plan for the best continued prenatal care.
PCOS is a hormonal disorder that is more commonly associated with infertility and the inability to conceive, but research shows that women who have PCOS and do get pregnant are also at an increased risk for miscarriage. It’s estimated to affect 6-10% of women in their child bearing years, but many more may be undiagnosed.
PCOS also increases the risk of women having pregnancy complications like gestational diabetes, preeclampsia, and having an infant who spends time in the NICU after birth.
The major link of PCOS to infertility and possibly miscarriage appears to be the link between insulin resistance. This means that the cells in the body are resistant to allowing blood sugar to come into them and the sugar levels in the blood remain higher for longer than in women whose cells are sensitive to insulin and let the blood sugar come inside. This mechanism also increases the risk of miscarriage in diabetic women.
Because the cells are not very responsive to insulin, the pancreas will usually increase production of insulin. This elevated insulin can lead to blood clotting and issues with the placenta. There are other mechanisms as well that seem to play a role.
PCOS (if suspected) can be tested through a variety of helpful markers, including the following:
- Fasting insulin
- Fasting blood glucose
- Hemoglobin A1C
- Cycle day 3 FSH (Follicular Stimulating Hormone)
- Cycle Day 3 LH (Luteinizing Hormone)
- Prolactin (Lactation hormone; too high levels can inhibit ovulation)
- Total testosterone (Levels of male androgens)
- Free Testosterone (Levels of male androgens)
- Estrogen (Estradiol)
- Sex hormone binging globulin (SBGH)
- AMH (Anti-Mullerian Hormone; Marker of Egg Reserve)
- Progesterone (done after suspected ovulation to confirm ovulation and/or adequate levels)
- Cortisol (Cortisol should peak in the morning and lower at night in rhythm with our natural circadian rhythm to allow us to sleep; Testing multiple times of day and through a saliva result is an option to understand the full day’s results)
- Full Thyroid Panel (as seen above; Hypothyroidism and PCOS can commonly go together)
- Celiac Testing or Elimination Diet with a skilled nutritional professional to see if you have Non-Celiac Gluten Sensitivity
If you have PCOS, a PCOS appropriate diet and nutrition plan, appropriate exercise, and working with your doctor to manage insulin and blood sugar can increase the chance of a healthy pregnancy. Working with a nutrition professional who specializes in PCOS (in addition to your doctor) can be extremely helpful to get the right support and help you increase your chances of a healthy baby.
8. Nutrient Deficiencies
I placed this reason last, because nutrient deficiencies themselves usually play a role in the onset of the other risk factors for miscarriage such as many of those listed above.
They are also important to note because if mom is already deficient, baby can receive inadequate amounts of nutrients during gestation and/or mom can enter postpartum even more depleted since the body prioritized giving baby the nutrients.
For example, selenium and iodine are critical nutrients for thyroid function. So the mechanism by which these deficiencies affect miscarriage may be by lowering thyroid hormone output and thus impacting egg quality, and even embryo development once the fertilized egg has implanted in the uterus.
Possible Nutrient Deficiencies
- Vitamin D
- B Vitamins:
- Iodine: necessarily for thyroid hormone production. You can test thyroid function first to determine if further iodine testing could be beneficial. If you don’t eat iodized salt, it’s especially important your prenatal contain an adequate amount
- Selenium: also necessary for thyroid hormone production. You can test thyroid function first to determine if further selenium testing could be beneficial. Studies have shown that women with thyroid antibodies
Taking a high-quality prenatal vitamin in addition to a whole foods diet for at least 3 months prior to trying to conceive can help reduce the risk of nutrient deficiencies that impact fertility, hormone levels, chromosomal abnormalities, miscarriage, and baby’s early development. To learn more about what to look for in a prenatal, check out my FREE handout here.
When You’ve Exhausted This List
If you’ve run the gamut on tackling all of things listed above and still running in to trouble, I suggest looking deeper into environmental toxins, infections (including STDs), inflammation, metabolic dysfunction, endometriosis, stress or trauma, and reproductive immunology such as the work of Dr. Alan Beers. You should also work with a doctor to rule out structural issues that could be contributing to or causing loss and/or infertility.
While this list is certainly not completely comprehensive, these are some of the main risk factors for miscarriage. The good news is that many of them can be corrected and thus reduce the risk of subsequent pregnancies also ending in miscarriage.
My wish is that preconception screening and care be more in-depth and widespread so that women can address any risk factors they may have BEFORE they conceive, and have the best chances for the healthiest baby possible AND a better postpartum period.
Are you planning a pregnancy or a pregnancy after loss and want more individualized support? Schedule your free 20-minute consult with me to get some ideas of next steps and support in your journey.
As with all content on this website, this is not medical advice but is shared for informational and educational purposes. For the full website disclaimer, please read here.