We grieved with Meghan Markle, Duchess of Sussex, who publicly shared the deep emotional pain of her miscarriage this past summer.
And then this summer, we celebrated the happy announcement of the birth of her rainbow baby, Lilibet ‘Lili’ Diana Mountbatten-Windsor.
The term “rainbow baby” is generally not a familiar term for those who have not experienced a miscarriage or stillbirth. But for those who have experienced this type of loss, it can be a very emotional, life-changing and isolating experience.
Symbolizing hope and healing, a rainbow baby is a healthy baby born after a miscarriage, stillbirth, infant loss or neonatal death. The arrival of a rainbow baby is also an emotionally life-changing experience for the parents and one of the most satisfying parts of my specialty.
Experiencing Loss Isn’t Uncommon
It’s difficult to estimate the exact number of rainbow babies born every year — largely because miscarriages often go under- or unreported. Many miscarriages occur very early in a pregnancy, too early for the woman to notice she is pregnant.
Having a miscarriage is devastating but not unusual. Statistics seem to indicate these losses are fairly common, estimated by the American College of Obstetricians and Gynecologists to occur in as many as 26% of all pregnancies and up to 10% of clinically recognized pregnancies.
But statistics are not always comforting to those women who have experienced a loss. Those who come to our practice are looking for answers about what caused the loss and what can be done to prevent a future miscarriage or stillbirth.
While maternal age and the number of prior miscarriages are risk factors, 50% of first trimester miscarriages in healthy women with no related underlying medical conditions occur due to a chromosomal abnormality — nature’s way of preventing an abnormal birth.
Chromosomal abnormalities can also be a cause of a stillbirth, which is defined as a pregnancy loss after the 20th week. The lack of preventive measures is a hard reality to swallow.
In addition to worrying about what they did wrong, women are often concerned about the prospect of conceiving again. Statistically, a single miscarriage or stillbirth (or even two in a row) is not a sign of infertility. Often, couples will have a rainbow baby on their own without the assistance of an infertility specialist.
But the fear of infertility often looms ominously and may prompt a visit to an infertility specialist.
When to See an Infertility Specialist
Here is what to expect in the hope you will be expecting:
Classically, women were referred to an infertility specialist for recurrent pregnancy loss, defined as the occurrence of three or more consecutive pregnancy losses. But according to the American Society for Reproductive Medicine, RPL is now defined by two or more failed clinical pregnancies.
In our experience, it makes sense to start the process of determining the underlying cause after two pregnancy losses rather than three, particularly when the woman is over the age of 35 and/or has had difficulty conceiving.
Dealing with grief and loss is the first step in the process.
Many people may find it surprising that the first step involves just offering support and encouragement. So many women have a mixture of feelings: grief over a loss, guilt for something they believe they may have done to precipitate it and fear they may not have another child. In our experience, dealing with those feelings of loss, grief or guilt can be an important step in the healing process and in taking the steps necessary to mentally prepare for another pregnancy and the promise of a rainbow baby.
Finding an Underlying Cause
The next step in the process is evaluating the physical health of both partners.
For females, a history is generally followed by a physical exam and then an ultrasound. which provides an initial assessment of the reproductive tract, including the uterus and ovaries. That process is generally complemented by bloodwork to evaluate the ovarian reserve hormone levels, as well as other hormones important in reproductive endocrinology.
After checking for clotting or bleeding tendencies, the physician will usually check for underlying medical issues. Sometimes, an in-office diagnostic hysteroscopy will be performed, where a camera is inserted in the vagina to check the uterus for any anatomical abnormalities such as polyps, fibroids or intrauterine adhesions.
For males, after a complete history and physical, we generally do a semen analysis to determine sperm volume, concentration, motility and morphology. In men of advanced age or who are at risk for having a high degree of sperm fragmentation, we often recommend a new diagnostic tool, the sperm chromatin structure assay, which detects small breaks in the sperm chromosomes that can affect the sperm’s ability to fertilize the egg.
Genetic testing for chromosomal makeup is usually recommended for both males and females.
Next Steps After Testing
Armed with the results of the tests, the couple, doctor and embryologist can explore treatment options depending on the results of the testing. There are so many medical options available to increase the probability of producing a rainbow baby.
For men, depending on the cause, there are medical and surgical options to either increase sperm counts, unblock an obstruction or extract sperm directly from the testis to help men conceive. Options may include oral medication, varicocele repair, cryopreservation and testicular sperm extraction.
The options for women also depend on the results of the physical exam and tests. For some women, removal of the polyps, adhesions or fibroids can lead to a rainbow baby. For those who have clotting tendencies, we have found success in initiating a protocol with Lovenox (a blood thinner) and aspirin.
Fertility Options Exist
For others, in vitro fertilization may be the best option.
IVF is a standard procedure offered to women who have recurrent losses due to chromosomal abnormalities. Thanks to the advances in preimplantation genetic testing, we now have the ability to detect abnormalities in the embryos and transfer only the normal ones to increase the chances of pregnancy. For patients with a family history of monogenic disorders (such as Huntington’s disease, cystic fibrosis and sickle cell anemia), there is a specialized way to identify which embryos carry the mutation.
One of the newer tests now available to IVF patients is endometrial receptivity analysis, where a sample of the endometrium is taken and sent for testing to determine the ideal window for implantation. The embryo transfer timing is then calculated to reduce the risk of implantation failure or miscarriage and increase the chances for a rainbow baby — because we believe rainbow babies are not limited to royals.
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