A newly conceived embryo has heavy odds against it. Up to 60% of all conceptions end within the first 12 weeks of gestation in its mother’s womb – in about half of the cases even before she is aware of the fetus’s existence. 12% to 15% of all clinically recognized pregnancies that survive that initial period fail and miscarry.
It’s quite a miracle that we have all been born, as our deliveries are the end (or the continuation) of a struggle for survival.
In fact, since the fetus is genetically different from the mother, one could wonder why it isn’t rejected by her body in every pregnancy.
Fortunately, in a pregnancy, half of the material is foreign but its development is gradual, so this does not result in an immediate rejection.
There are numerous women who manage to carry fetuses for a while but then suffer recurrent miscarriages.
The phenomenon is called recurrent pregnancy loss, defined as two (in the US) or three (in Israel) or more consecutive pregnancy losses. The causes of between half and three-quarters of all cases are never explained, making it all the more difficult and frustrating for the parents. Primary RPL is having two or three miscarriages one after the other, while secondary RPL is having at least one child after two.
About 1% of couples trying to have children are affected by recurrent miscarriages.
Even though RPL is common, only a handful of gynecologists are experts in it, and those who deal with the problem are usually experts in fertility (the desire to conceive), which is very different from ensuring that a fetus survives.
Thus when Prof. Asher Bashiri – the director of one of the five maternity departments at Beersheba’s Soroka University Medical Center – developed an interest in RPL, he found few experienced colleagues to speak to.
“RPL is discussed sometimes at fertility conferences, but they are busy with sperm donations, in-vitro fertilization, surrogacy and other subjects not relevant to recurrent miscarriages. These events usually don’t invest a lot of time discussing RPL. Colleagues of mine were very skeptical, saying that ‘nobody will come’ to the first conference, but they were wrong. In all of Israel, the number of experts in this specific field can be counted on the fingers of one hand. Because of my book and the two conferences, I get patients from around the country. We aim to set up a national RPL center at Soroka.”
Bashiri, with practical help from Dan Knassim, organized two conferences in the past two years in Cannes, France, and invited hundreds of physicians from more than 50 countries around the world – even from Iran, Kuwait, Saudi Arabia and Iraq – to attend.
He dreams of having a future conference in Jerusalem.
The first World Congress on Recurrent Pregnancy Loss was held in January 2016 at the Hotel Barriere Le Majestic in Cannes (where the film people also meet), while the second four-day event convened at the same venue a few weeks ago, each with more than 200 people attending and many of them lecturing on their research. A total of 400 different researchers attended the two gatherings. Bashiri seized the opportunity to raise awareness of the problem among doctors and promote international collaboration to advance knowledge about miscarriages, leading ultimately to finding a cure.
Unfortunately, he had to leave Cannes suddenly and attended only one day of the event, as his octogenarian mother – Flila Mina Bashiri – died suddenly the day before it opened. He had to miss the funeral after his rabbi advised him to open the conference and then fly home.
But on the morning of the first day of the event, he placed photos of her on the dais, dedicated the conference to her memory and received many messages of consolation on her loss from participants.
“She always prayed that as a physician I would never err. That message stayed with me during my medical career of giving patients difficult treatments,” he said.
Next year, the conference will be held in Venice.
BASHIRI HAS run a recurrent pregnancy loss clinic at Soroka for more than 15 years that has amassed a unique database with information on thousands of RPL patients at Soroka on all clinical aspects of the problem. Bashiri also serves as the director of the obstetrics and gynecology clerkship for advanced medical students at Ben-Gurion University of the Negev and advises more than 25 research students.
In an interview with The Jerusalem Post after his return, Bashiri said that he treated a woman who gave birth to two children after enduring 13 miscarriages. There is always hope, he said.
“The 2017 congress was an important platform to share the latest research and development on the sensitive subject of miscarriage,” said Bashiri. The Israel Healthcare Foundation, the US fund-raising subsidiary of Clalit Health Services (Israel’s largest health fund and owner of Soroka ) was one of the sponsors.
Among the subjects discussed were research conducted at Soroka Medical Center about infertility among women with recurring miscarriages; the significance of sperm selection to increase the chance of carrying to full term after recurrent miscarriages; uterine malformations and fetal abnormalities; how to emotionally support women who miscarry; and the relationship between recurring miscarriages and clotting.
“RPL is a very sad phenomenon, and it takes a significant emotional and physical toll on couples,” Bashiri noted. I wrote a medical textbook published last year by Springer Publishing, and the last chapter was on the perspective of parents.”
Scientific studies have shown that a significant share of women who had miscarriages became depressed and anxious, and in some, the psychological condition can continue for months or even years.
“Stress is big factor. We gave patients a psychiatrist’s questionnaire and found that all women who have suffered repeated miscarriages had a high amount of anxiety. Some women who have RPL are afraid of having an ultrasound or even going out of the house. Patients try acupuncture, support groups, yoga or a variety of relaxation techniques to help them relax.”
HE WAS born in Beersheba to parents who came here from Jerba in Tunis. He has eight brothers and one sister and is the only one to go into medicine. His father was a carpenter, an autodidact, after his aliya, and passed away a decade ago.
The gynecologist studied medicine at BGU and learned his specialty at Soroka, with a fellowship in the field of ultrasound at New York University.
Then he returned to Beersheba and since then has worked in the maternity department. His wife runs an elementary school in Omer, and they have four children aged 8, 11, 21 and 24.
“Given the high birth rate in Israel, there is a serious shortage of gynecologists. This is true especially in the South.
“More than half of our maternity patients are Beduin women,” Bashiri said, and some of them suffer from RPL.
The number of medical students has to be increased, especially as more than half of medical students are women, many of whom do not work full time, but even if this is carried out, more clinical-teaching places in hospital and academic physicians are needed, he added.
Even though so many miscarriages have no given cause, there are many known causes that trigger fetal loss.
Among them are malformation of the uterus, which is thought to be responsible for 15% of recurrent miscarriages.
The most common abnormality is when a partition exists in the uterine cavity, leaving no room for a growing fetus. The cervix, too, may be abnormal or weak. ] If one or both partners have chromosomal problems, this can lead to miscarriages in about 3% of cases.
Aneuploidy, in which the fetus has an improper number of chromosomes, may cause its spontaneous loss. This condition is more common when the mother – and sometimes the father – are older and their relevant cells are of lower quality.
Women suffering from hormonal problems, including polycystic ovary syndrome, are also at higher risk of RPL, as are those with a tendency for their blood to clot.
Even obesity can lead to RPL, said Bashiri.
“We find that very overweight women who undergo bariatric surgery to lose weight can increase their rate of successful natural pregnancies.”
Autoimmune conditions, such having anti-thyroid autoantibodies or antiphospholipid syndrome, is another factor. Chronic endometritis caused by bacteria has been found to be more comment in some women with a history of RPL and antibiotics may be a solution for some of them. High levels of natural killer cells (a type of white blood cells) in the uterus also are present in uterine tissue and raise the risk of RPL. So are ovarian factors in which a small amount of female hormones is produced. Having diabetes is also a significant risk factor for RPL.
Lifestyle factors such as smoking, drinking alcohol, being exposed to certain drugs and toxins can also cause fetuses to abort, said Bashiri.
WHEN A woman comes to the specialist’s office, she gives a detailed genetic, family, medical and surgical history and undergoes a physical exam, said Bashiri. The chromosomal makeup of each partner is usually performed as well to find abnormalities that may result in RPL. An ultrasound scan is also included in the tests, along with an x-ray of the uterus and fallopian tubes.
Treatment is very varied and depends on the perceived cause, or, if the cause of RPL is not clear, a number of approaches are attempted.
Sometimes Bashiri offers preimplantation genetic diagnosis, in which genetic defects in embryos are analyzed to see if certain diseases or conditions from being passed on to the fetus, followed by IVF of healthy embryos.
Women who have been through miscarriage should not wait until they are 40 to try again, said Bashiri, as time is needed for the problem to be solved. He also urges that couples have a regular follow-up at a clinic that is more familiar with RPL, rather than just going to their regular doctor.
As there are many Beduin cases in the Negev, Bashiri mentions the problem of consanguinity, in which Muslims marry first cousins. This is an independent risk factor for repeated miscarriages and causes a lot of genetic problems, he explains.
“We at Soroka organized a forum with imams to answer their questions about RPL, but the tradition of marrying close relatives is not likely to change in the near future, despite the medical problems it causes.”
What does Bashiri forsee in coming years? “I believe that we will be able to perform more individual investigations, give more treatments, offer personalized medicine and other solutions. Today, unfortunately, some doctors who deal with RSL don’t look deeply into the couple’s genetics and look only for pathology.
It seems to be because they want to save money, but in fact, if we find a genetic problem we can provide an answer. This saves money in the end.”
Bashiri plans to write new Israeli guidelines for the diagnosis and treatment of RPL, now that his clinic receives couples from around the country.