Recurrent miscarriage (embryonic abortion) is a complex disease, and it is not too much to call it a difficult disease. Patients are able to conceive but have recurrent spontaneous miscarriages (spontaneous loss of the embryo) or embryonic abortions (known as auditory miscarriage, a type of spontaneous miscarriage) during early pregnancy (within 12 weeks of conception), and the resulting mental stress is particularly high. Many people need to undergo repeated clearance procedures and suffer considerable physical damage. There is a lot of confusion among patients in the process of seeking medical treatment, as they do not know which doctor to call, which doctor to see, and what tests to do, because the doctors say different things; it is even more difficult to know how to treat them. Today, from the patient’s point of view, I would like to talk about how patients need to adapt and what problems they need to pay attention to. I know that all patients face their own condition, and the word “fear” is at the forefront of their minds. The pressure from within themselves, their families, and their surroundings all make it difficult for patients to sleep and eat. The pressure is less during pregnancy and more when you are pregnant. Some patients are particularly sensitive and find out they are pregnant early before their menstrual period arrives, so they start checking progesterone and blood HCG early and frequently ask the doctor if her results are normal; some panic when they see brown discharge and become restless, coming to the doctor once every 2-3 days to do tests, observe the doctor’s face, ponder his words and judge their own situation; some patients simply come to the doctor’s office. Some patients simply use contraception for several years, saying they want to get well before conceiving, but in reality they are afraid of getting pregnant and experiencing another miscarriage. As a doctor, I understand these extremely stressful situations. But if the doctor says there is no need to be afraid, does that mean the patient is not afraid? Although fear is fear, patients still need to know these facts: 1, early pregnancy bleeding does not necessarily mean that the fetus is not developing well. The clinical data proves that there is half a chance that the fetus can still develop normally if it bleeds during early pregnancy. Early pregnancy bleeding may be caused by the embryo eroding the small blood vessels in the meconium during implantation. There are some cases where a small amount of subchorionic bleeding occurs, which is able to be absorbed slowly. But after all, bleeding in early pregnancy is a sign of embryonic damage. Our attitude is not to be frightened by the bleeding but also to give full attention to it. When bleeding in early pregnancy is very small and there is no obvious abdominal pain, it is important to see a doctor, but it is not necessary to see an emergency room. You should ask your family to find an appropriate doctor, arrange for an outpatient visit within 1-2 days, and go to the doctor with ease. When the bleeding is heavy, resembles menstruation, or is accompanied by significant underground abdominal pain, or dizziness with a rapid pulse, you need to see an emergency doctor. It is important to clarify early whether the pregnancy is ectopic, or a refractory miscarriage. To clarify whether emergency uterine evacuation, or surgery is needed. Strict bed rest is not necessary in cases of minimal bleeding, and light activity is possible. Hemostasis should not be used easily; it may lead to insufficient perfusion of embryonic blood flow and aggravate embryonic damage. 2. Low progesterone and HCG at 5-6 weeks of early pregnancy may be normal. It is not necessary to check progesterone and HCG urgently, because when the embryo is implanted soon, the progesterone may be low and it will take some time before it goes up. Generally, a progesterone level of 25ng at 6-7 weeks of early pregnancy or more is a relatively safe level. As for the value of HCG, it is normal to fluctuate in a wide range. In the very early stage of conception, HCG is relatively low, but it may rise very quickly after some time, so HCG should depend on its dynamic changes. Other people have long menstrual cycles, ovulate late, and the fertilized egg is planted shortly after 5-6 weeks of menopause, so low progesterone and HCG are normal. It is better to recheck blood progesterone, Beta-HCG and E2 once a week. If you have not checked your A function, you should check your A function and blood glucose for the first time after pregnancy, especially the blood glucose 2 hours after meal, and ultrasound should preferably be done when the blood HCG reaches 2000 U or more, as the fetal sac may not be seen too early, and the interval between ultrasound is about 10 days. 3. The interval between the next pregnancy after the cleansing of the uterus should be about six months. Some patients just had a miscarriage, the endometrium has not been repaired, and then they got pregnant again, so they did not have a few months to clean the uterus again. Other patients are afraid of miscarriage and are afraid to try again for years, is this good? It depends on your age. Being young is the biggest cost of fertility. After 35 years of age, the ovarian reserve function decreases rapidly, so if you delay to get pregnant, the chance of success becomes smaller and smaller. The time cost is wasted by you. Therefore, if you are 32 years old or older, you should start trying to conceive six months after you have cleared your uterus. If you are close to 35 years old, you should start trying to conceive 4 months after you have had your uterus cleared, because it is not always possible to conceive right away, and you need to make an advance. You have to try even if you are afraid of pregnancy, you have to try to have a chance. As mentioned earlier, there are three main cases of recurrent miscarriages: biochemical miscarriages do not need to be cleared because no embryonic material can be seen in the uterine cavity, which is relatively less harmful to the patient; spontaneous miscarriages do not need to be cleared if they are clean, but there is some harm to the patient due to excessive bleeding. Some spontaneous miscarriages with residual uterine cavity still need to be cleared; patients with embryonic abortion (indolent miscarriage) are not so lucky and need to be cleared, i.e. the embryonic tissue in the uterine cavity is removed by negative pressure suction and scraping. This is because: 1) repeated scraping can damage the functional layer of the endometrium, which becomes very thin, reduces blood flow and even fibrosis, affecting the next embryo implantation. 2) after scraping, the endometrium can become very thin, which can affect the next embryo implantation. 2. Uterine adhesions after curettage are common, and moderate to severe adhesions can cause secondary infertility. This is an added problem for patients with recurrent miscarriages. One of the causes of post-cleaning uterine adhesions is related to the patient’s own constitution. Some patients have adhesions, such as those that occur with a single clearing, while others have no problem with multiple clearings. Longitudinal uterine patients are prone to adhesions after uterine removal. Secondly, it is related to the operation of uterus removal. Dead embryos are more tightly associated with the endometrium due to infection and mechanization, unlike fresh embryos which can be easily aspirated and scraping is inevitable. The main reason for this is that it is very important to know the degree of clearance of the embryo, so the clearance of embryonic abortion should be performed by experienced operators. There are other features of embryonic abortion: the dead embryos can release anticoagulant substances, causing bleeding during and after the operation; the dead embryos are often accompanied by infection, increasing the chance of uterine infection and adhesions; therefore, once the diagnosis of embryonic abortion is confirmed, the uterus should be cleared as soon as possible and a certain amount of antibiotics should be given during and after the operation. Some people who have known about the embryonic abortion have delayed the clearance procedure, increasing the risk to themselves. In summary, on the issue of clearing the uterus, patients should be aware that once the embryonic abortion is determined, the uterus should be cleared as early as possible; patients who need to clear the uterus should go to a regular hospital and find an experienced doctor to perform the procedure, which does cause some problems for the patient. This is because the patient is often the passive one and is not able to pick the doctor. Patients can only try to find an experienced surgeon to perform the procedure if they are able to do so; patients who have repeatedly had their uterus cleared several times, especially if they have had their uterus cleared more than 3 times before, should have a hysteroscopy procedure before their next pregnancy to exclude uterine adhesions. If the endometrial lining is thin after recurrent cleanings, estrogen and herbal medicine can be used to promote the recovery of the endometrial lining, which takes time to recover, so about six months should be the interval between pregnancies after cleanings. Both recurrent spontaneous miscarriage and recurrent embryonic abortion (detained miscarriage) are natural death of embryo, the former many people do not need to clear the uterus, the latter need to clear the uterus, but why there are these two different situations can not be explained yet, further research is needed. Other self-adjustment for recurrent miscarriages (embryonic abortion) A higher percentage (30-50%) of recurrent miscarriages are caused by endocrine abnormalities, and a significant percentage of these people have metabolic abnormalities or ovarian endocrine axis abnormalities (such as PCOS). Before seeing a doctor for recurrent miscarriages, it is best to do some self-examination, such as: 1. Is the body mass index over the limit? Strictly speaking the best body mass index should be between 20-22, less than 18 and more than 24 should be adjusted first (body mass index = weight kg/height meter squared, for example, if a person weighs 130 pounds and is 4000px tall, then her body mass index is 65/1.6 squared = 25.39). With an adjusted body mass index, metabolic abnormalities will improve significantly, and so will endocrine abnormalities. 2. Is the menstrual cycle irregular? Irregular menstrual cycle means irregular ovulation. Long menstrual cycle means delayed ovulation, accompanied by poor egg quality. Polycystic ovary syndrome is often accompanied by long menstrual cycles, and it is also common to have trouble conceiving, miscarrying or having embryonic abortions. A normal menstrual cycle is usually 3-5 weeks, but this is relative. The farther the cycle is from 28 days, the greater the degree of endocrine abnormality. Endocrine abnormalities can be regulated by herbs, ovulation-promoting drugs, and hormones that adjust the menstrual cycle. Obese patients will improve their endocrine secretion after weight loss. Is there any history of diabetes mellitus, previous births of huge children (suggesting hyperglycemia)? Any previous history of multiple abortions (which may cause uterine adhesions)? Is there any family history of genetic predisposition, such as a history of recurrent miscarriages or births of defective children by close relatives (suggesting chromosomal abnormalities)? Any history of recurrent reproductive tract inflammation (suggestive of TORCH or mycoplasma infection)? Any history of immune disorders such as rheumatism, any history of blood clots such as stroke, thrombocytopenia, transient black eye (suggesting positive cardiolipin antibodies)? Any hypothyroidism or hyperthyroidism? etc. All these may be related to repeated miscarriages. Fourth, the embryo has stopped developing many times, is there any hope for this time? This is the question that many patients ask the doctor, and it is also the most difficult question to answer. The doctor cannot project the success of your pregnancy this time, but can only give a probability. For example, if you have had one miscarriage, you have an 80% chance of success next time, if you have had two miscarriages, you have a 60-65% chance of success next time, if you have had three miscarriages, you have a 40% chance of success, and so on. In my clinical practice, those who have miscarried 5-6 times still have a chance of success. Even for those with heavy cavity adhesions and those who have had 5-6 miscarriages with hypothyroidism, there are people who can successfully become mothers. This depends on the one hand on finding the cause and correcting it to obtain success. On the other hand, it depends on the patient to try and give yourself a better chance. In many cases the doctor does not know how it worked and it is often a matter of chance. Regarding recurrent miscarriages, there are many successes, some luck and some helplessness. Let’s build up our confidence and go forward with courage like climbing a mountain.