loss (lol)

your "only" joy, Joanna? really?

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The good Dr. Nope has been going through it for the past several months. This essay discusses pregnancy loss and abortion. In a fun way!

i.

If you get to pick the setting for your third miscarriage in six months, you could do worse than the Louvre. Majestic cavernous rooms, hard marble floors and edges, a notable lack of precious crown jewels, some stiff physical and emotional boundaries around their sudden withdrawal. They don’t let enough people into the Louvre for it to get crowded, except in the Mona Lisa room. I snuck a glance at her, then took a picture of all the people taking pictures of her, and slipped around them to take in the paintings on the walls of her room (she’s in a bulletproof case in the center, like the Pope), which everyone else ignores, so they don’t feel so left out. In a certain hormonal mood, everything I do can be described as “maternal,” like “taking care of paintings and their feelings,” which is to say “lightly psychotic.” Delusions of reference, personhood, grandeur. This blood means something, and so do I. I will be the David Sedaris of pregnancy loss: funny and irreverent, but moving, and in Paris for some reason.

However, as a New Yorker, I must disclaim that the Louvre is not as good as the Metropolitan Museum of Art, which is down the street from where I had my last miscarriage, and has way better stuff.

*

As a woman of both regular menses and powerful circadian and seasonal changes in mood, I am accustomed to the constancy of the cycle. So in this there is some comfort. Every rise will be followed by a fall. There will be a fluctuation, and then a correction. Humans are one of the few animals with concealed ovulation, and my old IUD concealed mine even further, leaving me with only a medieval peasant’s understanding of my monthly tides. Go ahead, learned astronomer, show me all the charts and diagrams and models of the so-called solar system of tilting bodies and angles of light and shadow. All I can tell you is that the moon gets bigger and then it gets smaller. It’s dark and cold now, it will be dark and cold for a while, then it will gradually get warmer and lighter, in seasonal recapitulation of the way every night precedes every dawn.

Reproduction is actually a positive feedback loop, unlike the simple thermostat correctives of most of the body’s mechanisms. If your blood pressure is going up, your body will try to bring it back down. Whereas if there’s something growing in your uterus, your body will try to make it grow more, until it bursts forth expulsively. Ew. On the contrary, my relentless cycles of ovulation, fertilization, implantation, hormone production, growth, then cessation, then reversal, then some combination of shedding and reabsorption, seem a bit more natural, right? Seasonal. Tide comes in, tide goes out. If tide just comes in and in and in, that’s a disaster.

Of course, it’s called a natural disaster, and things that are natural may be good or may be bad, but at least they can be accepted.

ii.

Nowadays everyone wants to talk about miscarriage. They’re so common! We should talk about them! We don’t talk about them in our society! I think this has been accomplished, at least in my social circles. I don’t feel that the topic is particularly stigmatized, but it’s also unfun.

The less talked-about thing is early pregnancy itself. If I was just living my life, bopping around in my normal state of health, with only the dietary and energy restrictions imposed by my whims and afflictions, and then suddenly miscarried every month or two, this would all be indistinguishable from a series of irregular periods, and would be much easier to handle. Unfortunately, from my recurrent experience, the first month or two of pregnancy just sucks, and sucks far more because it is a Secret.

This secrecy is due to a combination of superstition, precautionary odds-playing, and politeness. Everyone Knows miscarriages are common (Half of all pregnancies? One in five pregnancies? As with everything pregnancy-related, laypeople will come at you with some powerful statistics, and anyone in the weeds with this data knows it depends on how you define certain things), so Everyone Knows you don’t announce your pregnancy until after a certain safe period, because announcing early spells doom, causes miscarriage, causes a series of awkward just-kiddings after the fact. But everyone needs an announcement past a certain point, because everyone wants to know if you are anticipating life’s greatest blessing and the most important thing that can possibly ever happen to you, or if you are simply getting fat.

I get all of this. I work in a garden full of reproductive-aged women in variously-flattering scrubs. The time you actually need to know if someone is pregnant is during the early days when it’s not physically visible, but the hormones are raging, and when you’re being yelled at by a mid-thirties cardiologist, it would be nice to know if she’s being a bitch because she really does think you’re that stupid, or just being a bitch in service to the perpetuation of the species. I can spot a first-trimester outburst from a mile away, which gives me the opportunity to duck. In a few years we’ll be past this as a cohort, when instead we give each other grace for the new-baby-at-home outbursts and the pumping-and-breastfeeding outbursts and the terrible-twos outbursts and the unreliable-childcare outbursts and the just-so-hard-to-be-a-working-mom outbursts and the perimenopausal outbursts, while the childless bear it and bear it. Then comes a decade or two of calm menopausal professional competence. Then the sweet embrace of the grave, the satisfaction of knowing I was a good friend and patient colleague to all those working moms, keeping my own mood stable and medicated in the face of these natural cycles. The rage and unreliability and general annoyingness of the pregnant coworker is revealed in the fullness of time to be foreshadowing for a happy ending, but for the recurrent miscarriage coworker, because it is all a Secret, it’s just character development.

For all the Republican senators reading this, in between staging funerals for my clumpy blastocysts and working to criminalize the medical care I received around their demises, let me just clarify for you how early pregnancy works:

Week 0-2:

This does not exist. For logistical reasons, pregnancy is counted from the first date of the last menstrual period. There is no such thing as “two weeks pregnant.” There is no precious little lifeform here, perilously close to having fingernails and a heartbeat and personhood, and thus necessitating your bullshit six-week abortion bans. Egg and sperm are in two bodies miles apart. Everyone calm down.

Week 2-3:

Egg is released (ovulation) at the beginning of this week. It erupts from the ovary, (hopefully!) lands in the Fallopian tube (the ovaries and the tubes are not connected! it can go floating through your abdomen!), and rolls down to the ovary like a tumbleweed over a few days. For effective conception, it’s actually best to have sex before the egg is even released. For effective contraception, after the sperm has occurred, you can take the Plan B emergency contraception pill, which is essentially a progesterone bomb, to delay ovulation for a few days until all that sperm gets cleared outta there. If ovulation already happened, Plan B cannot do anything. The journey has begun. Beware sex in the week or two after your period. Or enjoy!

Week 3-4:

Egg and sperm have combined (fertilization). Some people believe that life begins here. Sure, Jan. The fertilized egg keeps tumbling along and might well tumble out of the body (the theoretical “half of all pregnancies end in miscarriage” happens here) and grow up to be a menstrual period. If you truly believe that that beautiful never-implanted soul is just as worthy of personhood and mourning and a full Catholic funeral as the teenagers I’ve watched reckon with their mortality, suffer unduly, and then die of cancer, knock yourself out, but that’s a lot of mourning, dude. As far as the experience of pregnancy goes, there are still no symptoms here. Medically, “pregnancy” begins when the fertilized egg implants in the uterine wall.

Day 28:

Period is due. Generally this is when I take a pregnancy test and find out that the egg has implanted and it’s started spewing out enough of the hormone hCG to suppress menstruation and to make the pregnancy test turn positive. Hooray/uh oh! The first time this happened was a uniquely joyful and beautiful life experience. The second time was guarded: burned once already, statistically it probably won’t happen again but it could. The third time was just like, great, not another future miscarriage.

Week 4-8:

Haha, this is the part that sucks.

Early pregnancy sucks to experience and it sucks to learn about in the first three weeks of medical school, which is when we studied early embryology and had no idea what was going on. Drawings of what look like naked mole rats and homunculi, combinations of new Latin roots, “syncytiotrophoblasts”??? Fundamental layers of tissue form and combine. Curves and blobs. Something about ectoderm and the neural crest and the cardiac tube and the notochord. The host’s body is nourishing the growing thing and frantically scaffolding out an entire new organ (the placenta) to more perfectly nourish the growing thing in later weeks.

Gallons of surging hormones direct all these processes. In general, hCG makes you feel sick and estrogen makes you feel crazy and progesterone makes you feel off. You are SO SLEEPY, all the time. Irritable. Maybe nauseous. Foods and odors and digestion get weird. This combines illy with the New Rules. You can’t eat certain foods, take certain medications, do certain things. Or maybe you can but shouldn’t. Ask Your Doctor, except they understandably don’t want to see you before week 6-8 or so, because there’s nothing for them to do. So Ask The Internet! Maybe ask your mom or a close friend who’s been through it, who can look through their vast N=1 up to N=4 pregnancies on average, and reflect fondly on “oh, I was so nauseous!” or “you know, I really wasn’t nauseous!” You can only ask so many times a day, even of your mom, but you think about this whole thing constantly, because you’re constantly making decisions For The Future Baby, and trying to remember what the rules are, and then remember which of them you’ve decided to follow, while being SO SLEEPY, and by the way you’re Not Supposed to drink that much coffee, and you absolutely cannot take ibuprofen for the withdrawal headache.

The only rules people really 1000% agree on are “take folic acid every day, hopefully you started Week 0 by the way” and “don’t drink alcohol right now” and “don’t take teratogenic medications.” But in your mind, that turns into “don’t take ANY medications unless PROVEN safe,” which leads to more googling. You google and google. You weirdly can’t fall asleep despite being so sleepy, so this gives you more time to google. Now Google is tracking you and serving you a thousand ads per day, across all platforms, about starting a baby registry and buying baby products and choosing formula brands and diaper brands and stroller brands, babies babies babies, brands brands brands, ads making you aware of a common virus called CMV, which can irreversibly damage unborn babies. There’s no action item there. You get it from anyone anywhere anytime. But still, you should just, like, fear it, generally. (Conspiracy theory: mark my words, there will be a CMV vaccine in a few years, and the people who put out ads saying “be afraid of CMV” will sell it to us. I’d take a CMV vaccine but really, do we need this step?) Fear CMV and toxoplasmosis and parvovirus and Listeria. Be sleepy and kind of sick and think about all of this every minute of every day.

You’re bloated by progesterone and engorged with estrogen so none of your clothes fit right. You are drinking less coffee because increased caffeine intake is correlated to increased miscarriage rate except that’s probably just a function of people with more nausea drinking less caffeine and more nausea correlates to less miscarriage, so fuck it you may as well drink a little more coffee, if you’re (going to be) a bad mother anyway. You’re not nauseous so you’re probably going to have a miscarriage anyway. Your whole life is changing, you will be sleepy for the rest of your life.

Are you anxious? Are you depressed? You’re definitely worrying about a lot of things and you are too tired to do anything, sounds pretty anxious and depressed to me! You have a combined physical and mental illness which you have chosen to give yourself, again and again, and which you cannot tell everyone about, because it is a Secret. Okay, maybe you can tell your mom if your mom is cool, or a few close friends, or (me) whoever it occurs to you to tell because it’s YOUR life OKAY, even if it brings bad luck and you’re going to make everyone sad again with the retraction in a few weeks. Or you can just seem kind of sick and reclusive and bitchy. It’s cold out, the days are getting shorter, maybe it’s just the seasons. Cycles.

There are good things about early pregnancy, too, if you let them in. By the end of week 8, you start to think this one might actually stick. It’s a combined physical and mental illness which you have chosen to give yourself for a good cause, a noble cause, everyone in fact says it is the best cause in the world, definitely the only cause that matters. What if you get to the second trimester, which everyone says is great? What if you have a baby at the end of this? What if you love it even more than you love your cats? What if it loves you? What if it is funny and pleasant to be around as a 25-year-old? Your tits look amazing.

Week 6-10:

So in my experience, this is the part that goes from “sucks” to “REALLY sucks.”

One option is that you start bleeding and have your miscarriage in private, then you go in and get an ultrasound of your empty uterus to make sure it’s all out of there. You ask the OBGYN if they can see any proof that you were in fact pregnant, because this whole thing has felt like a hallucination and the barren ultrasound isn’t helping.

Or worse, you show up at 8 weeks to have your first ultrasound, you bring your partner for hand-holding and hope, then you get an ultrasound of a little sac rolling around (or two little sacs! Retroactive mindfuck, once it was twins!), and it doesn’t even look like a mole rat or a homunculus or an acquaintance’s grainy black-and-white post on Instagram. On the first ultrasound the doctors are also assuming this will be good news, so they let you watch. I know enough to know it’s supposed to look like a cartoon fetus. Never seen a cartoon fetus of my own yet. Forget the heartbeat you’re supposed to be able to hear now, there’s no heart. There’s not even polarity, no up from down. You’re pregnant, but you’re pregnant with nothing. The old joke is wrong, there is such thing as being “kind of pregnant.”

Technically, this ultrasound is not diagnostic of a failed pregnancy. Your dates could be wrong. You could have had a positive pregnancy test on day 28 but somehow, magically, you ovulated like the day before that, I mean pregnancy tests are so sensitive these days, so… okay, no, the math doesn’t make any sense, you’re eight weeks pregnant and that’s not an eight-week fetus (which remember is actually only six weeks since fertilization, and more like five weeks since implantation), this is very obviously a failed pregnancy, but technically it could be just an early pregnancy. The OBGYN knows you professionally and says, “Your dates are very reliable,” but you’ve been sick and crazy for at least a month and eating a lot of processed food, so are your dates very reliable? Are you?

The next step is to get a more detailed ultrasound in a few days, and then another detailed ultrasound ten days after that. By the way, all the ultrasounds are transvaginal, which are not painful for me but not really fun, as far as transvaginal experiences can be. Meanwhile, your body is still stuck around 4-8 weeks pregnant, so you’re still sleepy, irritable, can’t eat right, can’t eat what you want (because what if it’s a baby, it’s very obviously not but what if it’s a miracle baby and you killed it with the mercury from a spicy tuna roll?), no ibuprofen, no mild-altering substances in case they alter the non-existent brain of the little blob rolling around on those ultrasounds. You have plenty of time to consider the blob and its implications.

You are grateful for your education and professional experience, because that protects you from any real hope. There is no such thing as an eight-week embryo that’s just a little small, a little behind, maybe it will catch up later, have a growth spurt. In early pregnancy, embryology is very standardized. At 32 weeks, you can be small for your age, whether it’s growth restriction (bad placenta, infection, etc.), or because you’re just going to be a small person. At 8 weeks, you can’t be. You’re either an 8-week embryo, or the dates are wrong (they aren’t), or you’re a future miscarriage.

At the 10-day repeat detailed ultrasound, the tech scans frantically and keeps taking the same millimeter-measurements as last time with a poker face. You say, “It’s okay, I know what it shows.” When some subspecialist OBGYN you’ve never met comes in to break bad news and discuss your options, you say, “It’s okay, I’m a doctor, I’m a neonatal pediatrician, actually, it’s not viable, and I’ve like one D&C, please.”

You have three choices here: wait for a natural miscarriage, which may or may not finish on its own, necessitating a future procedure, or might just go bad and turn to sepsis inside you; take the abortion pill to help your uterus evacuate its derelict passenger; or get a surgical abortion. (I had a surgical abortion, which is technically a D&E but I think “D&C” sounds more familiar to most people, in which my cervix was dilated and the contents of my uterus were evacuated, no curettage needed. It was awesome and I would recommend it to anyone. Immediate relief of pregnancy symptoms, which were really making me miserable once the pregnancy was confirmed to be a non-baby. I experienced excellent sedation, no pain, and sensitive care at my own hospital. 10/10, 10 stars/10 weeks.) The medical procedures are exactly the same whether it’s for a non-viable pregnancy like this one, or for an incomplete miscarriage that has left some remnants behind, or for a viable pregnancy that some evil slut is terminating because of some stupid slut reason like not wanting to fulfill her only earthly purpose of producing a perfect Christian baby.

If you’re keeping track, in this timeline, I am now 10 weeks pregnant with nothing. In many states, an abortion at 10 weeks is illegal. If you think it should be illegal for me to have my nonviable 10-week pregnancy removed using medication or surgery, please tell me so to my face, so I can tell you to your face what I think of you.

Week 10-22:

Here be dragons. Both as far as the symptoms, which I haven’t made it to, and the embryology, which is still pretty weird but less abstract. Intestines shoot out of the body and go back in, branchial arches arc and cleave. Women glow and announce. Ugh.

Week 22-42:

This is where I come in professionally. Something emerges. Usually, it is born. The question of when it is what it is—fetus, baby, person, sort-of person, future person, crature, organism, animal, vegetable, miracle—is beyond science. I can tell you that I have caught 22-week babies that were very much alive and individual, in an alien sort of way, and I have said good-bye to 22-week fetuses that were never alive, and I have resuscitated full-term babies that were dead and later on became alive when I thought for sure they were permanently dead, and I know that at any age and size and gestation, there are so many things worse than death.

I believe more strongly than ever that abortion should be safe, legal, and unrestricted by gestational age, because gestational age is just one factor in the decision making. There are twenty-three-week fetuses that are people and forty-week fetuses that are not. Anyone who feels they can make laws and policies based on their firm understanding of the ironclad science is welcome to work in my job for a while and then to shut the fuck up. This is a moving science and probably always will be. Everything I thought was a binary is revealed on further study not to be a binary. Everything firm is shifting. Everything final is cycling.

iii.

At a dinner at a fine hotel near the Eiffel Tower, I met a beautiful gay Parisian art dealer (but I repeat myself) who told me some bad news about the crown jewels. I had just begun to feel familiar churning cramps, but still I declined to share unpasteurized cheese and uncommonly fine red wine and Gauloises, just in case this time it’s real. He told me that the Louvre’s crown jewels will certainly be broken down and sold. Duh. I was so naive. They have probably already been broken down into individual chunks, tiny diamonds and gems, broken down and resold in Antwerp, then resold and resold, unrecognizable fragments.

Crushing. I had pictured some underworld criminal wearing the tiara herself at the world’s most secretive parties. One wants the entire whole to be preserved, a beautiful thing like that, glittery with history and seduction and potential. Even if it was tucked into someone’s closet to be brought out only to impress the gangster’s new moll, to be rediscovered decades hence, that would be so much better. Better that than split into a thousand common little engagement rings. What good is that?

This was something beautiful, and when they see the remnants, no one will even know. So much potential. Now it’s just nothing.

Nothing at all.

From the Toxoplasmosis Files

Ironically, blood tests have recently confirmed that Dr. Nope has never been exposed to toxoplasmosis.