Barriers to Fertility Awareness Research and Miscarriage Risk Factors (Episode 568)

Full Transcript: Episode 568

Lisa: This is the Fertility Friday podcast, episode number 568.

I’m excited to share today’s episode with you because in today’s episode I have one of our past guests, Dr. Marguerite Duane, who is the founder of FACTS. I’ll share her bio with you and information in a minute. But what I’m excited about is that we actually touched on a topic that we weren’t necessarily planning on, something that’s really important and we haven’t really touched on formally in the podcast before. And we ended up spending the first half of our call talking about research and not just research in the general sense, but the process of getting research to be approved. And Dr. Duane talks about some of her challenges, even though she’s a medical doctor, getting research that she has done actually published in specific journals. And we talk about some of the politics behind that.

Although I feel like I’m quite familiar with a lot of that because I just, you know, spend so much of my time diving into research studies and I feel like I have a good understanding of that world, when I talked about it with our FAMM practitioners — so, you know, I had a call, one of our regular calls shortly after this interview — a lot of our practitioners were really surprised and a bit shocked to discover what kind of politics really go on behind the scenes.

So this is a big part of today’s episode. I think you’re really going to enjoy that, especially if you have questions, if you’re curious. And what’s interesting is that as somebody who shares a lot of research publicly, sometimes people come for me. It doesn’t happen all the time, but there’s the occasional trolling scenario where someone will come at me and, you know, you’re choosing this study that has a small sample size and where’s the rest of the data and blah blah blah. And we really get into some of the challenges behind that. I mean, sure, you can come for me and criticize the quality of the study. I often give that and share that when I’m doing the FAM research series. I’ll discuss often some of the limitations with the studies. There’s no study that’s perfect. But what’s interesting is that there are some compelling studies that show some really concerning results that do have smaller sample sizes. But what we don’t often see is the follow-up study. And we have to think about why that is. If there’s a study that’s highly critical of hormonal contraceptives showing a really negative result — so for example, the study with a small sample size showing that 100% of the participants had clitoral shrinkage to an average of 20% — that’s one of the scary studies that I’ve shared in my books and on the podcast. So if you have a study like that, is there a benefit to the drug companies who fund the research to do a follow-up with 2,000 women to show that 2,000 of them have this negative result? You know, probably not. And so I think sometimes when we’re being highly critical and nitpicky we have to look at also the bigger picture and ask the bigger questions of why don’t we have research in this area, or why don’t we have more research about this particular thing.

Now, the reason that Dr. Duane came on the show was to actually share about some of the recent research on miscarriage and to talk a little bit more about some ways that that could be presented. So we do get to that main topic towards the latter half of the episode. So both topics are really important. And before we jump in, I’ll just share a little bit about Dr. Marguerite Duane if you are not familiar with her work. She is a board-certified family physician. She is the co-founder and executive director of FACTS About Fertility, which stands for the Fertility Awareness Collaborative to Teach the Science. It is an organization dedicated to educating medical professionals and students about the scientific evidence supporting fertility awareness-based methods. She also serves as an adjunct associate professor at Georgetown and Duquesne University, where she is the director of the Center of Fertility Awareness Education and Research. Dr. Duane cares for patients via her own direct primary care house-calls-based practice, MD for Life, in the Washington DC area. Dr. Duane has a unique skill set in the area and field of fertility awareness as she is trained in multiple modalities including Creighton, FEMM, NeoFertility, and TeenSTAR. She received her MD degree from the State University of New York at Stony Brook, and completed her family medicine residency at Lancaster General Hospital in Pennsylvania. Dr. Duane is married to fellow family physician Dr. Kenneth Lin, and they are delighted to be the parents of four children. So without further ado, let’s go ahead and jump into today’s episode with Dr. Duane.

Lisa: And I’m so excited to be back again with Dr. Marguerite Duane. Welcome back to the show.

Dr. Duane: Thanks, Lisa. Delighted to be with you again.

Lisa: Well, it’s always a pleasure to talk to you. We were talking in the pre-chat — I had to hit record or we would have just talked for the whole day. It was really nice to catch up. But one thing I wanted to start with — would you share a little bit about what you’re working on now for anybody who is not as familiar with your work, and any updates around what you’ve been working on in FACTS as well, which is the Fertility Awareness Collaborative to Teach the Science. For any longtime listeners, you may already be familiar with Dr. Duane because she has been a guest on the show many times. And I often, when I talk about FACTS, it’s like, this is the thing that when all of these women learn about fertility awareness and they get all frustrated and they’re like, “Every woman needs to know — why don’t the doctors tell me?” It’s like, “Well, Dr. Duane is working on this for you.”

Dr. Duane: Exactly. You know, I’ve shared my own personal story that I graduated from medical school and was a doctor that didn’t know anything about female cycle tracking, cervical mucus, basal body temperature. It’s just not something that’s taught in traditional medical education, whether it’s medical schools, nursing schools, even midwifery schools. Many programs do not include basic education on the value of female cycle tracking and the use of fertility awareness-based methods. And so, as you know, that’s what inspired me to start FACTS About Fertility. We were originally the Fertility Appreciation Collaborative to Teach the Science when we first formed under the FMEC, but in terms of some exciting updates — because FACTS has been growing so much — it started out with this elective at Georgetown and conferences in the Northeast. We’ve expanded our reach not only across the United States, but in Canada, South America, Australia, Europe. We’re reaching medical professionals from around the world, educating them about the science underlying the female cycle. And so in 2023, we officially separated from our parent organization and formed our own nonprofit, FACTS About Fertility. That’s been a major shift, but it’s really allowed us to expand our programming. Not only are we teaching medical school electives, but now we’re doing resident electives, we’re doing conferences in person and virtual, and we’re seeing the impact. I mean, when I first started this work, there were maybe a few hundred doctors that were trained and knowledgeable about these methods — like in the United States and Canada — that’s not a lot of medical professionals. And yet in the last decade, we have trained over a thousand medical and nursing students who have taken our elective to learn about all of the evidence-based natural methods and the important role they play in reproductive healthcare. Doctors are the number one rate-limiting step. We are the biggest barrier to the widespread adoption of fertility awareness-based methods because many doctors simply don’t know. And I’m sure many of your listeners have had experiences where they’ve gone to the doctor and been dismissed when they shared their chart or tried to bring up some changes in their cervical mucus. So it’s really important the work that we’re doing. And we couldn’t do it without the support of our donors and the support of friends and colleagues like you who help us share the facts about fertility.

Lisa: And what I love about your approach — I mean, it’s a different world because you are a medical doctor. You’re affiliated with Duquesne University, like all the other universities you mentioned, and the work that you’re doing within the academic sphere. So what I really appreciate about your work is obviously how academic it is. And I also sometimes wonder when you sleep, because whenever I’m digging into research, your name pops up all the time. You’ve published or been on a team to publish a wide variety of papers within the last several years. I don’t know if you want to talk a little bit about that process because, like I said, you’re doing a lot to legitimize fertility awareness within the academic and medical sphere.

Dr. Duane: Yeah, thanks so much. I will say it always surprises me when people say, “Oh, you publish so much.” I’m like, “Really?” Because I feel like I have a stack of papers that are like written, ready to go, mostly written, need to be finalized, written, submitted, and rejected multiple times. So I will be honest — the research process is a very, very frustrating process. You know, I’m trained in family medicine and our focus is really on clinical care, but I recognized in this field, as I was teaching doctors and residents and students about fertility awareness-based methods, that we need more research. And so I did something crazy during the pandemic. I thought, for my midlife crisis, it would be a great idea to move my family of six from Washington DC to Salt Lake City, Utah in the summer of 2020. I moved to Salt Lake City to do a research fellowship under the direction of Dr. Joe Stanford, who has really been an incredible role model and mentor to me. That fellowship was a really incredible opportunity for me to fully understand the research process. My husband is also a family physician and an academic and an editor with the American Family Physician Journal. So he writes and publishes a lot. And when I get these rejection letters — or not even the rejection letter, but “we’re not even interested, don’t even send the paper” — I’m like, it’s so frustrating. But many people around me encouraged me to keep going and keep pushing forward. And I realized it is so important. We need the science out there because women need access to this information.

There are still so many papers. Like, we did a paper on the patient experience talking with their doctors about their use of fertility awareness-based methods, and one of the most interesting findings from that study was that a third of patients said that they were laughed at, mocked, or ridiculed by their medical professional for their use of fertility awareness-based methods. And I’m like, that’s unconscionable. I mean, as a doctor, there are many things that my patients do that I don’t necessarily agree with, but we need to work with and try to understand our patients. So that’s a paper I would still love to get published. And I just want to put this out there now because I think this is super exciting — and I didn’t even tell this to you in the pre-chat, Lisa. Here’s a news flash: my colleague, my mentor, Dr. Joe Stanford, with the team at the International Institute of Restorative Reproductive Medicine, as of Sunday, February 2nd, launched a new journal on restorative reproductive medicine to get more of this research published. And it’s so important. And honestly, what I decided to do my research on — the topic that drew me in — was the topic of miscarriage, and how can we identify modifiable risk factors of miscarriage, because it’s such a common condition.

Lisa: Well, I definitely want to dive into the miscarriage topic. One thing I wanted to say though — I really appreciate you sharing just that little tiny window into the research process, because I just have a different perspective. I’m not the one writing the research papers, but I spend a lot of time reading them. And we live in a time when I think it might be shifting a little bit. Medical doctors have a little bit more leeway because of their authority to say things even if they don’t have the research to back it up. I without the MD on my name — everything I say is under the microscope. So I have taken an almost clinically insane level approach to the research, because since I don’t have the letters beside my name to just say whatever I want. And the point that I’m making is that we live in a time where we do need to have that research to back up what we say, at least in some situations. But it can lead people to think that research is infallible. And it can prevent people from really looking critically at this whole concept of research and publishing and journals. It is not objective, and it is a publishing process. So certain ideas are published and certain ideas are not published. So I really appreciate you sharing that.

Dr. Duane: Yeah. And let me just share — one of the research articles that I am most proud of is the article that Dr. Stanford, Dr. Pruznik, Dr. V. Hill, and I published in 2022. It’s the overview — fertility awareness-based methods for women’s health and family planning — and we did a comprehensive review of the literature. There are over 100 citations in this paper where we looked at the role of fertility awareness-based methods in women’s health and its effectiveness both in preventing and achieving pregnancy. And because I felt this article was so important and that many doctors needed access to this information, I submitted a proposal to have it published in the American Family Physician Journal — the most widely read medical journal in circulation. When the proposal got to the editor-in-chief’s desk, they wouldn’t even consider it. I was really upset and angry as you could imagine. We ended up submitting that paper to like two to three different journals. But I think the other thing that’s important for people to be aware of is that research takes money — and a lot of money. And in the field of fertility awareness, there’s not a lot of money. People aren’t going to make a lot of money teaching women how to chart their basal body temperature. So there’s not a lot of money to do the research. And as one of my colleagues and again another tremendous mentor to me, Dr. Phil Boyle, who is a family physician in Ireland and the founder of NeoFertility, he likes to say — just because it isn’t published doesn’t mean it isn’t done or that we don’t know the information.

And the challenge is that somebody like Dr. Boyle, who’s primarily a family physician in clinical practice, sees the results in his patient population. But trying to get that data published is really, really hard. And it’s even harder when it goes against mainstream medicine. I know for a fact that Dr. Boyle and colleagues have a paper that’s been rejected multiple times because it looks at a comparison of the effect of restorative reproductive medicine treatments in the treatment of infertility versus IVF. And the reality is the success rates with RRM are much higher and the cost savings to the healthcare system are much greater. And yet, because it does not shine a positive light on the conventional IVF industry, he’s had a very difficult time getting that paper published. The research has been done — it just hasn’t been published.

Lisa: Yeah, like I said — being in the midst of research, I think it was a really interesting direction that just organically happened. And when people say, “Oh, you don’t have any evidence for this and you don’t have evidence for that” — that might be true, but just because it isn’t published doesn’t mean it isn’t there. And just because it hasn’t been put in a specific journal doesn’t mean it isn’t true. It’s a little more gray than we’d like. It would be better if we had research for everything, but there are solid barriers for that right now.

Dr. Duane: And it’s funny because you mentioned it’s a little more gray. There is actually something that we referred to as the gray literature — evidence that is circulating in the mainstream medical community, maybe a research study that was presented at a medical conference. The data exists in the conference proceedings but it hasn’t been published. And the reality is we need more. When I decided to do this fellowship, Dr. Joe Stanford was the head of the Office of Cooperative Reproductive Health at the University of Utah — the only office or center at any medical school focused on fertility awareness research. But the good news is because of the work that I have done with FACTS About Fertility and in educating the medical community and building a research database, that actually brought me to the attention of the dean at Duquesne University’s College of Osteopathic Medicine. Duquesne University is a university in Pittsburgh, Pennsylvania. Just last summer, in July of 2024, Duquesne launched a new College of Osteopathic Medicine — and what was unique is that when they launched the new medical school, they also launched a Center for Fertility Awareness Education and Research. And I’m proud and excited to say that I was hired as the first director of this new center — in an effort to integrate education about fertility awareness-based methods into mainstream medical education and also to build a research database and get more research published.

Lisa: We need to take a minute to just hover over the fact that Duquesne University decided to do this new medical school and opened a center for fertility awareness research. I was doing a little happy dance when you mentioned that and I was like, how did that happen? Like, this is what dreams are made of, at least in my community.

Dr. Duane: Exactly. And it happened because of a gift from a family — a family that said, “We want our family members to have access to this kind of care.” Access to physicians and other medical professionals trained in fertility awareness and restorative reproductive medicine is still really, really hard for many people to achieve. And so this family, through their generosity, made a very generous gift to train the next generation of medical students at Duquesne in these methods and to fund the research so that doctors from Pittsburgh and Pennsylvania and the United States and the world can have access to standardized restorative reproductive medical protocols. Just in January, we applied for grants through Duquesne to help with developing standardized protocols. And from a FACTS perspective — we also contracted with a professional research librarian to help us build a database of research articles related to fertility awareness and restorative reproductive medicine to make that available to members of the FACTS community.

Lisa: And I have one more comment. Like, we’ve talked about so many different things, but ultimately this change is coming because individuals like yourself, like myself, and like that family are deciding that this is important and taking action. It’s not just going to happen. And had you not been doing this for over a decade — had you not been making a big stink about it for a very long time — this opportunity would not have fallen into your lap. So congratulations. This is all wonderful. Fertility awareness is growing up.

Dr. Duane: Oh my gosh, it’s like going to your first school day, going to university — like fertility awareness is going off to college! And I love being able to celebrate with you. I just want to celebrate your 10-year milestone. I’ve been on your podcast quite a bit, but it’s awesome to see how much this podcast has grown up. When FACTS became our own nonprofit and we left the FMEC, I tell people I felt like I graduated from college and now I’m moving out of my parents’ house and I live in an apartment — some days I have money to pay rent, some days I have money to buy food, some days both. But it really does depend on individuals. This family gave a significant gift to Duquesne University, but FACTS itself — we subsist in large part on the support of our donors. In 2025, our goal is to recruit 25 donors that will give FACTS $25 a month. It’s not a lot, but it really does make a difference. I started FACTS in 2010 and it was fully volunteer until like 2016, 2017. We’re now getting into nursing schools. And there are more medical schools opening up and reaching out saying, “How do we integrate this into our curriculum in Kansas, in Ohio?” So it’s really exciting to see the change happen.

Lisa: And of course we’ll have all the links and all the information for anyone who’s listening on the show notes page. Okay, so we were going to talk a little bit about miscarriage today. I want to shift and talk a little bit about miscarriage. You know, when we were having our pre-chat, you started by asking me if I had had a miscarriage — because miscarriage is so common that as soon as you start talking about it, it just comes out of the woodwork. It wasn’t until I had an early miscarriage before I had my first son and I talked about it that everyone I knew was like, “Oh, I had one. Oh, I had four.” And like — you never told me! So let’s talk a little bit about the stats and how common it is, but also some of the research that you’ve been doing in this area and the implications.

Dr. Duane: Yeah. No, absolutely. Miscarriage is so common and yet it’s also a secret. So many women keep it a secret. And part of it’s like the way we approach pregnancy — so many women are encouraged like, “Oh, don’t tell anybody you’re pregnant until you’re 12 weeks and you’re sure it’s going to stick.” I mean, regardless of whether or not the pregnancy continues or you lose the pregnancy, once you’re pregnant, it has a huge impact on you physically, emotionally, socially as you begin your journey to motherhood. And yes, people experience miscarriages at different phases, and it may impact women differently, but the bottom line is it impacts many, many, many women. And you know, as a physician, we learn the statistic — oh, miscarriage happens about 15 to 20% of the time. So that may not seem like a lot — 1 in 5, 1 in 6, right? But when I teach my medical students, I ask them to think about what is that 15 to 20% of? What is the actual number of miscarriages? And in the United States of America, the most recent data that I’ve looked at from 2022 showed there were 3.66 million live births. So if you’re looking at 15 to 20%, you’re looking at about 540,000 to 720,000 miscarriages — a half million to potentially over a million miscarriages. There are some statistics that say in the United States there are up to a million miscarriages that occur.

Now, in the United States, we do not actually track miscarriage as a cause of death. And from embryological development, we know that the human heart begins to form and begins to beat at about 3 weeks post-fertilization, which translates into about 5 weeks along in the pregnancy. And when we look at miscarriage rates, we’re looking at miscarriage rates between 5 to 12 weeks. So if you have about a million miscarriages — women losing a baby after 5 weeks — if we actually did count that as a cause of death in the United States, it would be the third leading cause of death, after heart disease and cancer. Right now in the United States, February is heart disease awareness month. I can’t turn on a television without seeing something about heart disease awareness — and there are all of these initiatives and programs and foundations around cancer. That is all good and we should be focusing on that. I’m a family physician — prevention is core to what I do. But we need to look at that with miscarriage. If it’s the third leading cause of death, what are we doing to prevent it? And the reality is the way we’re conventionally trained in medicine is that miscarriage happens, it’s common. We don’t begin to even look into the underlying causes of miscarriage until a woman has had at least two or three miscarriages.

And so my goal as a family physician with additional training in restorative reproductive medicine is to prevent miscarriage. Tying this back to the research — when I did my research fellowship with Dr. Stanford at the University of Utah, I chose to study miscarriage. My specific question was, does a short luteal phase increase the risk of miscarriage? And I’m glad that I did study this topic because personally, everybody is affected by miscarriage — whether they themselves have had a miscarriage or somebody in their family. I just want to pause here for your listeners to say that although you may not have experienced being seen in that miscarriage, I just want to acknowledge your loss and let you know that I see you in this and my heart goes out to you. I’ve had patients that have lost one or two pregnancies or babies to miscarriage. I’ve had patients that have lost eight to 10. And it doesn’t matter whether it’s one or 10 — each one matters and each one really does make a difference. So I just wanted to take a minute to pause and recognize that. Because for many of these women, as you alluded to, many of them may be living in silence because they haven’t shared — because, although miscarriage is common, we’re often discouraged from speaking about it. And I think women should be encouraged to say as much or as little as they want, but we should create an open environment for them to share — so we can help them not only in the recovery process but work with them to see if there are underlying risk factors that we can identify and address.

Lisa: Absolutely. I appreciate you for saying that. You know, I think women’s experience of miscarriage is so varied. And even when I was sharing about my own experience with miscarriage, which was at the five-week mark, I’ve often felt that kind of tendency to downplay my own experience because I know that there are women out there who’ve had later-term miscarriages, stillbirths, multiple losses. And I think that we all have a tendency to do that. It’s very interesting to hear you put miscarriage into a different perspective — comparing it to all-cause mortality rates to find that it would be the third leading cause of death. It really shows how far-reaching this issue is and gives you some insight as to how many women are affected by this, yet to your point, we don’t talk about it at all.

So did you want to talk just a bit about — because it’s common knowledge in my world that typically unless a woman has experienced like three miscarriages, the doctors don’t even talk about it. Do you want to talk a little bit about what you found in your research that could reduce the risk of miscarriage?

Dr. Duane: Yeah. I definitely want to talk about it. I think when we look at miscarriage and the risks for miscarriage, we need to talk a little bit about the elephant in the room. The most significant risk for miscarriage is the age of the mother. Some would argue, well, is age a modifiable risk factor? I mean, I am the age I am. I can’t turn back the clock. But could we modify how we educate and encourage and support families to have children? In the United States, there’s such a push for people to really establish themselves in their professional careers and delay having a family. And the risk of miscarriage goes up dramatically starting around 35. So the more that we can do to create a system where it’s easier for people, if they so choose, to have children at a younger age.

Now, to the question of why doctors don’t look into the cause of miscarriage until a woman has had two or three — part of the reason is that the research shows, from older data, that about 50% of miscarriages are due to genetic abnormalities with the embryo. If there’s a genetic mismatch, it’s very unlikely that there’s going to be anything we can do to fix that. But the reality is — if 50% are due to genetics, that means 50% are due to other factors. So one in two times, there are factors that we can change. Some of these may be anatomic factors, like women with a bicornuate uterus or fibroids. Some may be due to hormonal issues — low progesterone, low estradiol, things like that. Some may be due to other underlying diseases like diabetes and thyroid disease. Some can be due to environmental factors. So there are so many factors that can affect a woman’s ability to carry to term. And if a woman is having multiple miscarriages, it often reflects less an issue with the particular embryo, and more likely an issue with maternal health, anatomy, or environment. And these are things that we really need to look to address.

I didn’t share this with you in the pre-chat, but yesterday morning I got a text from a patient with four beautiful pictures of her baby girl that she had after seeking care with me after having had three miscarriages. And in her case, like in many of my patients, it’s often times underlying hormonal issues. So I’m regularly using progesterone to support the luteal phase and to support the pregnancy. There was a research article published about a year ago by Dr. Phil Boyle demonstrating the importance of estradiol. We often think of progesterone as important in pregnancy. But in this study, Dr. Boyle found that in women with normal progesterone, if their estradiol was low, their miscarriage rate was 45%. One in two experienced miscarriage — three times the normal, the average rate. And so he found that in giving estradiol, the miscarriage rate was reduced to 21%, which is great — it dropped by almost half. But the reality is estradiol can increase your risk for blood clots and there are other risks. So instead, he started giving women DHEA, which is a hormone that the body uses as a building block to make estradiol. And in that population, the miscarriage rate dropped to 17%. So it dropped back down into that normal range.

Another hormonal issue — and I think this is an important one because I tell my family medicine colleagues we really play an important role in this — is thyroid. Thyroid hormone is so critical to overall metabolic health, and it’s especially important in early pregnancy when we’re basically growing a new human being. According to most labs, a normal TSH, or thyroid stimulating hormone — which is the test we most often use to screen for thyroid disease — the normal values according to traditional labs are anywhere between 0.5 and 4.5 or 5. But there’s research from the American Society of Reproductive Medicine that shows women with a TSH greater than 2.5 — which is right smack dab in the middle of that normal range — have a statistically significant higher rate of miscarriage and infertility. So we do need to be more aggressive at identifying and treating thyroid. When I get a new patient and she says, “Oh, I had my thyroid checked and it was normal” — I’m like, “What was the lab and what was the value?” Because it may have been normal according to normal lab standards, but if it’s higher than 2.5, you may still be at higher risk. I have a patient who had a terrible miscarriage and terrible post-miscarriage depression, and she was able to conceive within six months because we addressed her underlying thyroid issues.

Lisa: Well, so a practical question — and there’s no perfect answer, obviously — but for a woman who has had a miscarriage or more than one and maybe has attempted to approach her physician and hasn’t been well received or has been kind of pushed off, what, if anything, would you want her to know in terms of an approach to get answers or to find the right provider that might be willing to help her look deeper?

Dr. Duane: Yeah, great question. And I’m going to pause here because you said the word “provider,” which is a trigger word for me — like nails on a chalkboard. I like to refer to physicians, nurse practitioners, midwives as medical professionals, because as a “provider,” the idea is like you’re the customer and I’m just going to give you what you want. And the reality is that we’re professionals and we have to make decisions about what is actually in your best interest. Now, the challenge is most medical professionals don’t know what testing they need to order. Many doctors won’t even look at that until a woman has had three miscarriages. And so one of the things — we just applied for grant funding, and one of the areas we’re going to focus on is developing standardized protocols for how to evaluate women and their risk for miscarriage and what we can do to reduce that risk. So fingers crossed the grant will come through and by the end of 2025 we will have protocols on that.

But what I would want them to know now — where I would encourage them to look for research — is on our factsaboutfertility.org website. We have written about Dr. Boyle’s article. We have written about thyroid. And there’s a great article in the American Family Physician Journal on thyroid disease in pregnancy — what they state, according to the research article, is that women who have a history of hypothyroidism who are on levothyroxine, if they have a positive pregnancy test, they should increase their weekly dose of levothyroxine by 5 to 10% of that weekly dose. So if you have thyroid disease, find this article, print it out, bring it to your physician, your midwife, your medical professional, and share this information. I mean, you know this, Lisa — you said you love research. There’s a gazillion articles out there. It’s hard for doctors to keep up. But if you can go to the source and have a research article — Lisa, I’m going to share these research articles with you specifically so you can include links to them in the show notes so people don’t even need to leave your website. We encourage them to visit factsaboutfertility.org, but you’ll have it for them there so they can share the science and raise the question about what should be done to minimize their risk of miscarriage.

Lisa: Yeah, no, I really appreciate that. And it is always tricky to navigate this conversation between you and your doctor. But at the end of the day, when you go and see your doctor, you and the doctor are in the sandbox and you have to figure out how you’re going to play nicely. We hope that your doctor will be open and respectful. And ultimately what I always say is — if you went to a hairdresser and the hairdresser laughed at you and said, “That’s such a dumb idea,” you wouldn’t actually continue to pay this person money or let them anywhere near your hair. I think we should take the same approach. Not that we’re dismissive — I think we always need to be respectful. But at the same time, I think we do have to take the onus of finding the doctor, the medical health practitioner, who is going to take you seriously and actually just hear you out. It’s supposed to be two ways — shared decision-making.

Dr. Duane: And to be clear — it never bothers me when a patient comes in and says, “I did my research.” Because there are so many areas where I am not well-versed. And I’ll be honest, it drives me crazy when patients come and say, “Well, I saw this on Google” — like, but what’s the source? If you can go to the source and have a research article, I appreciate it because I’m like, “Oh, you saved me the trouble of having to do the search myself on PubMed.” So I do appreciate that, especially when they’re coming in with scientific articles. But it is a difficult dynamic because there is that power differential.

And I want to encourage your listeners — I am always happy to talk to fellow medical professionals. I’ll share a story: last year, one of our FACTS speakers reached out to me because she had a client who had had miscarriages and was pregnant again. And this client was actually seeing a Creighton medical consultant. She felt like they weren’t really looking beyond progesterone. And I was like, well, they need to look at this, they need to look at that — I mentioned Dr. Boyle’s article. And I said, “You know what? I’m happy to have a conversation with your medical professional. Here’s my number. Feel free to connect them.” Anybody can reach one of my FACTS colleagues at [email protected]. I love to teach my colleagues. And the reality is most doctors, they do want to help patients. It’s just hard when there’s so much to learn and so much to keep up with. So if there’s a glimmer of openness, say — “Would you be interested in talking with another doctor who’s an expert in this field? I’d be happy to get you connected.” We can’t see every patient, but I do want to help patients get the care they need. And if that means connecting them with a doctor in their community or via telemedicine that can help address those underlying issues that may be leading to increased risk of miscarriage or infertility, or even painful periods in your teenage daughter — whatever it is — at FACTS, we want to help.

Lisa: Yeah. As we start wrapping up — you’ve shared such a wealth of information with us today. Let us know all the places where everyone can find you and what you have coming up.

Dr. Duane: Yeah, absolutely. We encourage people to visit our factsaboutfertility.org website. Our in-person conferences — we’re now doing those at the beginning of the year — but we will do a virtual conference in the fall. We do have an online continuing medical education course now approved through the American Academy of Family Physicians for 13 parts, each worth 16 CME credits. And while the content is geared towards medical professionals, anyone is welcome to register to participate in the live case study sessions or watch the recordings and read the research articles. We do have a number of sessions on miscarriage and recurrent pregnancy loss. Visit factsaboutfertility.org under “learn more” and enroll in our CME. And if you want to email us, email us at [email protected]. And if we can help you get the care that you need and deserve — or connect you with the medical professionals that can provide that comprehensive restorative reproductive healthcare — we are happy to do so.

Lisa: Wonderful. Well, we will make sure to include all the links and everything that we mentioned in the show notes. And I just want to thank you again for being here.

Dr. Duane: Thank you, Lisa. It’s always a joy.

Lisa: Thank you for listening. If you enjoyed today’s show, please share with a friend. You’ll find the show notes page for today’s episode over at fertilityfriday.com/568. I hope that you enjoyed today’s episode with Dr. Duane. We covered two really important topics. I just think it was such a great opportunity to dive into this topic of research and really get into some of those politics — like which papers are published, which papers are not, why not, who has the money to fund research — so that we’re not looking at the field of research as this infallible thing where everything we want to know has already been studied. It’s just not true. When I dive deep into the research weeds, it doesn’t take me long to find a lot of different areas where it’s very hard to find research. And one of the questions I often say is: who’s paying for it?

I could think of several examples. There’s inconclusive research at times on withdrawal as a method of birth control because there are some studies that show that none of the men had semen in the pre-ejaculatory fluid — which would be the whole point, because that’s the piece of information we’re curious about. Because if yes, then that could mean this method couldn’t work; if no, then it could mean that it is a legit method and it could explain why withdrawal does have a pretty decent effectiveness rate when used perfectly. So again — when something like this comes up, the question I often ask is, well, who’s paying for this? There’s no money in a method of birth control you can literally just do without buying anything. The drug companies make billions of dollars, so if they just say, “Oh, this is a super effective method that you could do at home with absolutely no payment to anybody” — maybe they’re not going to publish that, and maybe they’re not going to find the funding to do it. And often when I’m looking for specific fertility data or women’s reproductive health data, it’s in the IVF research that I find some of those answers — because again, where is the money?

So like I said, this conversation with Dr. Duane was really, really insightful and I’m really glad that I got to share it with you. Of course the discussion that we had about miscarriage is equally important. It’s an incredible topic — it’s an incredibly sad topic, but it’s an incredibly interesting topic when you get into it. Especially because many women who experience miscarriage often think that it’s something that only they have experienced until they speak to anybody — friends, family, strangers — and you just realize how common it is. Miscarriage is extremely common. An average of one out of every five pregnancies ends in miscarriage, and that changes with age. As we get older, a higher percentage of pregnancies end in miscarriage due to complications related to aging and increased instances of chromosomal abnormalities and oxidative damage to DNA. There’s a whole lot to be said about this topic and a lot more education that can be done. And theoretically, a lot of miscarriages could be prevented with proper education, information, even proper planning. It doesn’t mean every one could be prevented — I think there’s a lot about it that we don’t know. But obviously a really important topic. And I was really happy to have Dr. Duane here today to talk about both of these issues. So if you enjoyed today’s episode and you can think of someone who would benefit from hearing it, the share link is fertilityfriday.com/568. And with that said, I hope you have a wonderful weekend whenever you’re tuning into the show. And of course, as always, until next time — be well and happy charting.