Science writer Jon Cohen set out to better understand the causes of miscarriage after he and his wife experienced four failed pregnancies. In his new book, “Coming to Term: Uncovering the Truth About Miscarriage,” Cohen looks at medical studies and explores personal stories of miscarriage to better comprehend this sensitive and complex topic. Here's an excerpt.
On a brilliant, warm San Diego Saturday in the spring of 1996, my wife, Shannon, had her first miscarriage.
Our bafﬂing, heartbreaking journey into the world of what doctors call “spontaneous abortion” began with a phone call. We were having a lazy brunch with my parents on our front porch, pine trees shading us, the Paciﬁc Ocean visible in the distance. Our daughter, Erin, nearly six, was chattering with her dolls in the pine needles. Paging my way through the newspaper, I struggled to dodge conversation with my folks, who were visiting for the weekend and would rather talk than read. Then the phone rang, and Shannon excused herself to answer it.
Shannon is close to my parents, but had grown weary, as had I, of my mother’s well-meaning but insensitive probing about our reproductive status. Any luck? my mother would ask, month after month, noting that a cousin of mine recently had succeeded with in vitro fertilization. You really shouldn’t wait. You really should have started earlier. Maybe you should see a specialist. Maybe there’s something wrong with your sperm. Maybe you should do IVF. I’ll help you pay for it. You two should have another. It’s a shame. For Erin’s sake. She shouldn’t grow up alone. My kids always had each other to play with. There must be something you can do.
So it was with great delight that a week earlier, we had Erin phone my mother and tell her that Shannon, then thirty-seven, was pregnant. She was only four weeks along, too early to see anything with an ultrasound scan, but a blood test already had confirmed the positive urine test we had done at home. We even had a due date. My mother squealed, really squealed, with joy. She advised us not to tell anyone else until the baby was three months along, but at every opportunity she exclaimed, “Finally!”
A few days after sharing the news, we drove to Los Angeles for Passover dinner at my aunt and uncle’s house. Erin had already leaked the news to her cousins, and because Shannon’s pregnancy with Erin had gone so smoothly, we ignored my mother’s warning, celebrating our good fortune with all ﬁfty of my relatives. Shannon also conﬁded to my uncle, a doctor, that she had been spotting blood, but that her obstetrician had said it was common and usually means nothing. My uncle agreed. “Everything is probably going to be ﬁne,” he said.
Shannon’s spotting continued, and we read everything we could ﬁnd to help us understand ﬁrst-trimester bleeding, which doctors often refer to by the frightening phrase “threatened abortion.” Sometimes, when the embryo implants itself in the uterus it causes bright red bleeding for a few days. But this blood was brown and had continued staining Shannon’s underwear for several days. Sometimes, bleeding occurs after intercourse because hormonal changes make a pregnant woman’s cervix more exposed and delicate. Some women spot throughout their pregnancies for no known reason and without any harm to the child or the mother. Depending on whom you believe, 15 percent or 25 percent or 35 percent of women spot during their pregnancies and 25 percent or 35 percent or 50 percent of these women miscarry.
Obstetricians sometimes prescribe bed rest to prevent miscarriages, but most often they do nothing. In part, the reluctance to intervene comes from the diethylstilbestrol ﬁasco that surfaced in the 1970s. More commonly known as DES, this synthetic form of the hormone estrogen was widely used as a miscarriage treatment in the 1940s and 1950s. Reports began to surface in the 1950s that questioned whether DES might actually increase miscarriage rates, but the drug remained popular into the 1960s. In 1971, following a report that linked DES to a rare vaginal cancer in female offspring of mothers who took the drug, a bulletin from the U.S. Food and Drug Administration urged doctors to stop prescribing DES to pregnant women. Subsequent studies have found that DES caused infertility in exposed female children, genital abnormalities (of uncertain consequence) in both males and females, and may also have increased breast cancer in treated mothers. Recently, concerns have surfaced about the health of DES grandchildren.
The day we returned from Los Angeles, Shannon saw her obstetrician, who took a blood test. A six-week-old embryo should secrete increasing levels of the hormone human chorionic gonadotropin, or hCG. Home pregnancy tests turn positive when a woman’s urine contains a high enough concentration of hCG. The hCG keeps a pregnancy viable by telling the body to keep producing two other hormones, progesterone and estrogen, which help prepare the wall of the uterus for implantation and prevent menstruation. The doctor told Shannon that if the embryo was healthy, hCG levels should double every two to three days. The phone call that Saturday morning was the doctor. “I’m really sorry to tell you this, but your numbers have plateaued,” the doctor told Shannon. “It’s not viable. You’re going to miscarry within twenty-four hours.”
An ashen Shannon returned to the porch, and pulled me aside. She whispered through suppressed tears, “Ask your parents to leave.” Shannon then went inside and fell on the sofa, forming a ball.
That afternoon, the intense cramps of labor walloped Shannon. By evening came the heavy, seemingly endless ﬂow of blood that marks a ﬁrst-trimester miscarriage.
Human beings are notoriously inefﬁcient baby makers. A woman who is trying to become pregnant will succeed, on average, one out of every four menstrual cycles. According to a landmark study published in 1988, 31 percent of pregnancies end in miscarriage. So for each menstrual cycle, a sexually active woman not using birth control has less than a 10 percent chance of carrying to term. It is a wonder that we have an overpopulation problem.
Shannon and I had never thought much about fertility. We quit using birth control when Shannon was thirty-one (I’m ﬁve months younger), and she became pregnant in her ﬁrst cycle. I announced our good news at my ofﬁce, stupidly joking about how all I had to do was look at Shannon and she became pregnant. A woman I worked with excused herself. Later, she told me that she and her husband were having fertility problems. I learned fertility lesson number 1: your good news is not necessarily good news to others.
Shannon’s ﬁrst pregnancy progressed precisely as described in the stack of new books cluttering our coffee table. We marveled at each ultrasound scan, thrilling at the window into the womb and each discernible human feature of our creation. When the doctor put a microphone on Shannon’s belly, we delighted to the sound of our baby’s resonant heartbeat. At the baby store we bought not just a crib but, in a joyous moment that underscored how certain we were that everything would be ﬁne, a beach chair for a one-year-old.
Everything was ﬁne. Erin was born in Washington, D.C, at Columbia Hospital for Women, with ten toes, ten ﬁngers, and no complications whatsoever. When we wanted another child, we ﬁgured, we would stop using birth control again.
We didn’t want another child right away. We both had demanding careers, and we also wanted to return to our roots in California before adding to our family. And four or ﬁve years between kids seemed like the right spread, a chance for each child to enjoy our full attention.
In 1994, back in California, we rented a house with an extra bedroom and abandoned birth control again. A few months went by, but no pregnancy. The ob-gyn said not to worry: Given that Shannon was ﬁve years older, the odds of becoming pregnant in a single menstrual cycle had dropped from 25 percent to 10 percent. In a year’s time, then, she should be pregnant.
But after a year, we began to suspect that something was wrong. Maybe it was me. I take a steroid, from time to time, to treat ulcerative colitis. Or maybe it was Shannon. She takes strong drugs for her migraines. Or Shannon’s eggs. Or my sperm. Maybe we should see a fertility specialist. Maybe we should listen to my mother and try in vitro fertilization. Weighing these possibilities wore us down. Each of us felt guilty for secretly hoping that the other person’s body had caused the problem. We worried that seeing a specialist would open a ﬂoodgate of expensive, painful, and often futile interventions. Yet as the months passed, I found myself lobbying for that option. All that friction disappeared of course in the spring of 1996. Relief washed over us when Shannon tested positive. But the miscarriage that followed mocked us, illustrating how naïve and overconﬁdent we had been about our fecundity.
Six months later, more frustrated still, Shannon agreed to see a specialist praised by a friend. At our ﬁrst meeting, this likable doctor expressed dismay about what she saw as our casual approach to the pregnancy dance. “You’re subfertile,” she said. A woman’s “fertility window” begins to shrink dramatically at thirty-ﬁve, she explained. We thought our odds would plummet after we turned forty, not thirty-ﬁve. The “subfertile” label chagrined us. I, in particular, wanted to read the scientiﬁc evidence behind the doctor’s claims, which seemed to annoy her.
At the specialist’s suggestion, Shannon started taking Clomid (clomiphene citrate), a fertility drug that stimulates an egg to mature and move to the surface of an ovary, the process known as ovulation. And on the doctor’s advice, I had my sperm checked. Normal count, the lab said, but their swimming skills, daintily referred to as “motility,” did not impress. After a few cycles on Clomid with no success, we upped the ante with intrauterine insemination.
On the carefully chosen day based on Shannon’s ovulatory cycle, she drove Erin to school in the morning, providing me with a few minutes to deposit my seed into a sterile container before our doctor’s appointment. But shortly after Shannon left, a magazine editor phoned me with deadline questions about one of my stories. When Shannon returned, the container sat empty. She was livid. “I can’t believe this,” she said. “I have to put my body through torture, and you can’t even do the one thing you have to do. You’ll do it on the way.”
“I can’t do that,” I said.
“Get in the car,” she fumed.
So as we drove along the freeway, I tried to do my thing, but, well, it’s not easy when your wife is giggling at you and you’re cruising down the interstate, a pea coat over your lap, in clear sight of other morning commuters sipping their coffee. As we exited the freeway ﬁfteen minutes later, I still hadn’t made much progress.
“Damn it, do it!” barked Shannon. Somehow, I did, and just as I did, I noticed a guy riding a bike staring at me.
We dropped off the container at the clinic and went out for breakfast while the lab prepared my sperm for the procedure. When we returned, Shannon changed into a ﬂimsy hospital gown and lay down on the examining room table. The doctors drew my sperm into a syringe and coupled it to a catheter. A team of nurses and I watched as a doctor wiggled the catheter up to Shannon’s cervix and pushed the syringe plunger, sending my sperm on the journey to ﬁnd one of her eggs. This isn’t making love, I thought. It’s making babies. The insemination failed. I was not surprised.
We tried intrauterine insemination again at the peak of Shannon’s next cycle, which fell on Christmas Eve. There was holiday magic in the air. Wouldn’t it be wild? Again, no luck.
The side effects of Clomid limit the number of cycles during which a woman can safely take the drug. By spring, Shannon had reached her sixth and ﬁnal cycle on the ovary stimulant. Rather than try intrauterine insemination one more time, we opted for the natural approach — well, seminatural, given the Clomid — and, lo and behold, her period was late. But we did not rush to buy a $15 home pregnancy kit. Buying the kit at ﬁrst suspicion, we had learned, needlessly unleashes demons. A late period has an ambiguity to it that a pee stick does not. Too many times we succumbed to the delusional drama of the pee stick, watching the second hand on the watch in frantic hopes that the test would turn positive. Too many times had we felt completely deﬂated both by the result and by our foolish willingness to, once again, embrace odds-defying optimism. Too many times we ended up feeling like Lotto players holding a losing ticket, cursing ourselves for having dumped money on a dream.
Our resolve gave way ﬁve days later, while vacationing in Mexico. We ﬁnally found a urine test in a dust-covered box in a little-trafﬁcked pharmacy. We bought it anyway, and anxiously waited for Shannon’s pee to highlight the enthralling “plus” symbol on the blank white stick. The stick soon showed a minus sign, but, in our delusion, we convinced ourselves that it was really a minus sign with faint traces of the plus sign poking out — if, that is, you held it in just the right light.
Were we winners or losers? On the plane home, Shannon started to spot. Her period soon followed. Her doctor later concluded that she had had her second miscarriage.
Excerpted from "Coming to Term: Uncovering the Truth About Miscarriage,” by Jon Cohen. Copyright ©2005. Used by permission of Houghton Mifflin. All rights reserved. No part of this excerpt can be used without the expressed written permission of the publisher.