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Sitting in an exam room at the Duke Fertility Center, Nida Allam decided she wanted to share on social media something that only she and her immediate family members knew: She’d had a miscarriage.
It was August 9, and by that time, a little over a month had passed. Being at the clinic reminded her of what she had lost, but also of what she could have. It was exciting and terrifying at the same time, she wrote.
Wearing a white hospital gown over a black long-sleeve top and her hijab, Allam took a selfie from the mirror in the exam room. She wrote in her post that she was restarting fertility treatment. By sharing the message publicly, she hoped other women who had experienced what she had might not feel alone.
‘Difficult and daunting’
Allam, 27, is a Durham County commissioner, one of five women currently representing the county’s 320,000 residents. She was born in Canada to an Indian father and Pakistani mother who moved the family to the Triangle in the late 1990s for work.
She got involved in politics after her friends Deah Barakat, his wife Yusor Abu-Salha and her sister Razan Abu-Salha were killed by a neighbor in their Chapel Hill apartment in 2015.
When she was elected in March 2020, she became North Carolina’s first Muslim-American woman in office.
Shortly after her campaign, Allam and her husband, Towqir Aziz, decided to get checked before trying to get pregnant.
“We wanted to make sure we were doing everything we could to increase our chances,” Aziz said.
The couple spent several months trying to conceive. Dr. Noor Alshibli, Allam’s obstetrician-gynecologist, told them it was time to see a specialist.
“(The doctors) did a bunch of blood work and stuff to see if there were issues with my thyroid, checked my hormone levels ... everything.” Allam said. “They weren’t able to find anything.”
She requested an appointment in September 2020, but because of COVID-19 precautions had to wait until February, when after more tests she was diagnosed with “unexplained infertility.” Her specialist explained her treatment options.
“(In vitro fertilization), unfortunately, is very, very expensive, and insurance doesn’t cover it,” said Allam, whose out-of-pocket costs would have been about $15,000 per treatment. “The doctor suggested that I start with (intrauterine insemination)”
With intrauterine insemination, the sperm is collected from a partner, treated and concentrated, and then injected directly into the uterus.
For in vitro fertilization, on the other hand, an egg is removed from the uterus and fertilized with the sperm outside the uterus until an embryo is formed. That embryo is then transferred to the uterus via injection with the help of an ultrasound.
Success rates vary by age. One report shows that live birth rates at the Duke Fertility Center for women under the age of 35, like Allam, are about 67%.
Her doctors said she might have to go through at least three or four cycles of IUI before moving to IVF, but after her first IUI cycle, Allam noticed her period was late.
After several at-home pregnancy tests came back negative, she called her doctor, only to be told they would not do a clinical pregnancy test until she got a positive result at home. Toward the end of May, she did.
Based on her late menstrual cycle, doctors estimated Allam was two months pregnant.
“It was, like, an immediate roller coaster,” she said, fighting back tears.
“I made a gift basket of books and a T-shirt that said “No. 1 dad.” I set it up on the counter with the pregnancy test,” she said. “And I recorded (Towqir) coming home to see me showing him all of that.”
Once her pregnancy was confirmed, Allam had to return for blood work to check her hormone levels.
In June her human chorionic gonadotropin level started dropping, a possible sign of complications.
“It unfortunately kept dropping,” Allam said. “At that point, the doctor told me, you know, ‘I’m really sorry, but unfortunately, you lost your pregnancy.’”
Allam and Aziz were distraught.
“No one really talks about what actually goes on behind the scenes, like the stress and the emotional weight that it takes to start a family,” she said.
“I got excited really quickly (about becoming a parent),” said Aziz. “I was kind of surprised by how much grief I felt, and that was difficult to deal with.”
After the heartbreaking news, Allam thought she’d stop going to the center for checkups and have time to grieve.
Her pregnancy was ectopic: The embryo had implanted outside her uterus. While her hormone levels kept dropping, they never fell entirely to zero.
Allam had to keep going in for tests and treatment, all while working from home as a commissioner.
“We had our commission meetings, and everything kind of went on as business as usual,” she said.
“I didn’t share with my board members what I was going through because there’s this stigma around women’s reproductive health and, you know, expressing any sort of pain,” she explained. “It gets interpreted as a weakness.”
The American College of Obstetricians and Gynecologists says miscarriage is the most common form of pregnancy loss. Up to 26% of all pregnancies end in miscarriages, and 80% happen in the first trimester.
Grief and support systems
Weeks after the miscarriage, Allam catches herself asking what she might have done wrong.
“Did I move a wrong way? Did I pick something heavy up? Did I eat something wrong?” she said.
A devout Muslim, she prayed about those feelings of guilt and started researching what Islam says about miscarriages. One reading brought her the most comfort:
“When the gates of heaven open for you, that child will be waiting for you as soon as the gates open.”
“Reading it gave me this sense of ease that I would still be able to meet that baby,” Allam said..
Prayer was a central part of her parents’ grieving process, too. But there was another person who understood there was a pain that not even prayer would soothe.
Allam says her sister, Arsheen, has been her biggest advocate throughout her fertility journey.
“It reached the point where I just started taking her to the doctor’s with me,” she said.
Their bond became especially important when Arsheen defended her sister’s decision to share her miscarriage on social media to their father.
It started when their mother’s relatives called, concerned for Nida. Allam’s parents didn’t know how they had found out about the miscarriage until the relatives told them they’d read her social media posts.
Her father asked Arsheen to ask her sister to take the posts down.
“I said, ‘Well, a lot of women go through this and they go through it alone. And I don’t think that’s right,’” Arsheen told him.
“And the bravery that Nida is having by putting it out there, I think it will do a lot more good than to hide from it or be ashamed by it,” she said. “There’s absolutely nothing shameful about what happened.”
That conversation changed her father’s perspective, Arsheen said. It helped him understand the value in creating awareness about pregnancy loss and reproductive health, she said.
“That was amazing because our parents, they are immigrants. They have been raised thinking this is a shameful or private thing that you don’t talk about. That you don’t share,” Arsheen said. “We don’t even talk about our periods, let alone a miscarriage.”
Representation in health care
Dr. Noor Alshibli, one of Allam’s many providers over the last year, is an OB-GYN resident physician at Duke University. Her parents are Syrian immigrants of Muslim faith.
“Seeing the struggles that my parents went through as immigrants has given me an appreciation for a lot of my patients and the struggles they’re going through,” Alshibli said. “Even though I didn’t experience it myself, I’m able to at least consider some of the things that they might be going through.”
She and Allam met during one of the commissioner’s appointments with the supervising physician Alshibli was shadowing at Duke. Allam had no problem with that doctor but felt a connection with Alshibli.
“She didn’t even talk about Islam or anything, but it’s definitely like I felt more comfortable around her,” Allam said.
As a visibly Muslim American, Alshibli says people of different racial and ethnic backgrounds, and of other diverse identities, feel comfortable sharing their medical concerns with her. Many have experienced Implicit bias, or unconscious stereotypes some people hold about groups of other people, she says.
“It is very comforting for a patient to not only be heard, but to have someone who understands their background,” she said.
In the Muslim faith and culture, for example, menstrual bleeding patterns affect the sacred rituals that women are allowed to perform. For example, women on their periods traditionally do not have to participate in fasting and praying during the month of Ramadan, which celebrates the revealing of the Qur’an to the Prophet Muhammad.
“Being aware of that should be a part of all OB-GYN training, to know that that is a part of the patient population that you’re treating,” she said.
It’s also important to remember that not all people who share an identity will feel the same way during an exam.
“Even being a Muslim woman myself, I’ve met patients who declined pelvic exams, unless it’s absolutely necessary. And I’ve met patients who are completely comfortable with it,” Alshibli said. “I’ve met patients who prefer female providers and those who don’t mind. And that just goes to show you that even within a specific faith group, there are people of broad strokes.”
Allam has always found physical exams intrusive, she said, adding “(Alshibli) actually took the time to comfort me.”
It was Alshibli who referred Allam to the specialists at the Duke Fertility Center, where she recently resumed IUI treatment after a two-month break to allow her body to process the rest of a chemo medication and expel her miscarriage.
Although difficult, Allam says this journey has helped her prioritize self-care.
“I think this experience was like a trigger point for me,” she said. “I started going back to therapy, and this made a huge difference with processing (the miscarriage), but also processing the entire experience of going through fertility treatments and how draining and taxing it is.”
Allam and Aziz are also connecting with other Muslim Americans trying to become parents through support groups on social media.
“I was so amazed because I’ve never seen the Muslim community openly having those conversations and that really encouraged me to be more open about my experience because other women need to know that it’s OK,” she said.
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