Unfortunately, sometimes a pregnancy ends without the dreamed-of outcome. There is no new baby to hold in your arms.
If this is your situation, it’s likely a time of grief, confusion and fear. While understanding why miscarriage and other forms of pregnancy loss occur won’t stop the emotional pain, it may help you understand why your care provider recommends certain types of care.
In addition to miscarriage, pregnancy loss can take many forms, including ectopic pregnancy, molar pregnancy, preterm birth and stillbirth. Each has different causes and treatments.
MISCARRIAGE
Miscarriage is the spontaneous loss of a pregnancy before the 20th week. About 15 to 20 percent of known pregnancies end in miscarriage. But the actual number is probably much higher because many miscarriages occur so early in pregnancy that a woman doesn’t even know that she’s pregnant. Most miscarriages occur because the fetus isn’t developing normally.
Miscarriage is a relatively common experience — but that doesn’t make it any easier. A pregnancy that ends without a baby to hold in your arms is heartbreaking.
TYPES OF MISCARRIAGES
Depending on what he or she finds on examination, your care provider may have a specific name for the type of miscarriage you experienced:
Threatened miscarriage. If you’re bleeding but your cervix hasn’t begun to dilate, you’re experiencing a threatened miscarriage. After some rest, such pregnancies often proceed without any further problems.
Inevitable miscarriage. If you’re bleeding, your uterus is contracting and your cervix is dilated, a miscarriage is inevitable.
Incomplete miscarriage. If you pass some of the fetal or placental material but some remains in your uterus, it’s considered an incomplete miscarriage.
Missed miscarriage. The placental and embryonic tissues remain in the uterus, but the embryo has died or was never formed.
Complete miscarriage. If you’ve passed all of the pregnancy tissues, it’s considered a complete miscarriage. This is common for miscarriages occurring before 12 weeks.
Septic miscarriage. If you develop an infection in your uterus, it’s known as a septic miscarriage. This may demand immediate care.
Signs and symptoms Signs and symptoms of miscarriage include:
Vaginal spotting or bleeding
Pain or cramping in your abdomen or lower back
Fluid or tissue passing from your vagina
Keep in mind that spotting or bleeding in early pregnancy is fairly common. In most cases, women who experience light bleeding in the first trimester go on to have successful pregnancies. Sometimes even heavier bleeding doesn’t result in miscarriage.
Some women who miscarry develop an infection in their uterus. If you experience this infection, called a septic miscarriage, you may also experience fever, chills, body aches and vaginal discharge that’s thick and has a foul odor.
Call your doctor if you experience:
Bleeding, even light spotting
A gush of fluid from your vagina without pain or bleeding
Passing of tissue from the vagina
You may bring tissue that’s passed into your doctor’s office in a clean container. It’s unlikely that testing could define a cause for the miscarriage, but confirming the passage of placental tissue helps your doctor determine that your symptoms aren’t related to a tubal (ectopic) pregnancy.
Causes Most miscarriages occur because the fetus isn’t developing normally. Problems with the baby’s genes or chromosomes typically result from errors that occur by chance as the embryo divides and grows — not due to problems inherited from the parents. Some examples of abnormalities include:
Blighted ovum. Blighted ovum is common. It’s the cause of about half of all miscarriages that occur in the first 12 weeks. It occurs when a fertilized egg develops a placenta and membrane but no embryo.
Intrauterine fetal demise. In this situation the embryo is present but has died before any symptoms of pregnancy loss have occurred. This situation may also be due to genetic abnormalities within the embryo.
Molar pregnancy. A molar pregnancy, also called gestational trophoblastic disease, is less common. It’s an abnormality of the placenta caused by a problem at the time of fertilization. In a molar pregnancy, the early placenta develops into a fast-growing mass of cysts in the uterus, which may or may not contain an embryo. If it does contain an embryo, the embryo will not reach maturity.
In a few cases, a mother’s health condition may play a role. Uncontrolled diabetes, thyroid disease, infections, and hormonal, uterine or cervical problems can sometimes lead to a miscarriage. Other factors that increase a woman’s risk of miscarriage, include:
Age. Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it’s about 80 percent. Paternal age also may play a role. Some studies indicate that the chance of miscarriage is higher if a woman’s partner is age 35 or older, with the chance increasing as men age.
More than two previous miscarriages. The risk of miscarriage is higher in women with a history of two or more previous miscarriages. After one miscarriage, your risk of miscarriage is the same as that of a woman who’s never had a miscarriage.
Smoking, alcohol and illicit drugs. Women who smoke or drink alcohol during pregnancy have a greater risk of miscarriage than do nonsmokers and women who avoid alcohol during pregnancy. Illicit drug use also increases the risk of miscarriage.
Invasive prenatal tests. Some prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage.
WHAT DOESN’T CAUSE MISCARRIAGE
Routine activities such as these don’t provoke a miscarriage:
Exercise
Lifting or straining
Having sex
Working, provided you’re not exposed to harmful chemicals
Seeing a doctor If you’re experiencing symptoms or you feel that you may have experienced a miscarriage, contact your care provider. He or she will instruct you on who you need to see and when. In some circumstances, you may be instructed to go to a hospital emergency room.
Your doctor is likely to ask you a number of questions, including when was your last menstrual period, when did you begin experiencing symptoms, and have you had a miscarriage before? He or she may also perform one or more of the following tests:
Pelvic exam. Your doctor will check to see if your cervix has begun to dilate.
Ultrasound. This helps your doctor check for a fetal heartbeat and determine if the embryo is developing normally.
Blood tests. If you’ve miscarried, measurements of the pregnancy hormone, HCG, can be useful in determining if you’ve completely passed all placental tissue.
Tissue tests. If you have passed tissue, it can be sent to the laboratory to confirm that a miscarriage has occurred — and that your symptoms aren’t related to another cause of pregnancy bleeding.
Treatment If you haven’t miscarried but are at risk, your doctor may recommend resting until the bleeding or pain subsides. You may be asked to avoid exercise and sex as well. It’s also a good idea to avoid traveling — especially to areas where it would be difficult to receive prompt medical care.
With the use of ultrasound, a doctor can determine whether the embryo has died or was never formed — and that a miscarriage will definitely occur. In this situation, there are several options to consider. Before the use of ultrasound in early pregnancy, most women didn’t know they were destined to have a miscarriage until it was already in process.
Expectant management If you choose to let the miscarriage progress naturally, it usually happens within a couple of weeks after determining that the embryo has died, but it may take up to three to four weeks. This option is known as expectant management. At that time of the miscarriage, you may experience heavy bleeding and cramping, like a period, which could last for several hours. You may also pass some tissue. Your care provider can advise you how to handle this tissue. Usually the heavy bleeding subsides within a few hours and light bleeding continues for several weeks. This can be an emotionally difficult time. If the miscarriage doesn’t happen spontaneously, medical or surgical treatment may be necessary.
Medical treatment If after a diagnosis of pregnancy loss you prefer to speed the process, medication may be used to cause your body to expel the pregnancy tissue and placenta. You can take the medication by mouth, but your care provider may recommend applying the medication vaginally to increase its effectiveness and minimize side effects, such as nausea, stomach pain and diarrhea. The miscarriage will likely happen at home. The specific timing may vary, and you need more than one dose of the medication. For most women, treatment works within 24 hours.
Surgical treatment Another option is a minor surgical procedure called suction dilation and curettage (D&C). During this procedure, the doctor dilates your cervix and gently suctions the tissue out of your uterus. Sometimes a long metal instrument with a loop on the end (curet) is used after the suction to scrape the uterine walls. Complications are rare, but they may include damage to the connective tissue of your cervix or the uterine wall. Sometimes surgical treatment is necessary to stop the bleeding.
Recovery Physical recovery from miscarriage generally takes a few hours to a couple of days. Expect your period to return within four to six weeks. Call your care provider if you experience heavy bleeding, fever, chills or severe pain. These signs and symptoms could indicate an infection. Avoid having sex or putting anything in your vagina — such as a tampon or douche — for two weeks after a miscarriage.
If you experience multiple miscarriages, generally more than three in a row, consider testing to identify any underlying causes — such as uterine abnormalities, coagulation problems or chromosomal abnormalities. In some cases, a care provider may suggest testing after two consecutive miscarriages. If the cause of your miscarriages can’t be identified, don’t lose hope. Even without treatment, about 60 percent of women with repeat miscarriages go on to have successful pregnancies.
Emotional healing may take much longer than physical healing. Miscarriage can be a heart-wrenching loss that others around you may not fully understand. Your emotions may range from anger to despair. Give yourself time to grieve the loss of your pregnancy, and seek help from those who love you. Keeping the loss to yourself isn’t necessary. Talk to your care provider if you’re feeling profound sadness or depression.
Most women who’ve had a miscarriage go on to have successful pregnancies. Your care provider may advise you to wait awhile before becoming pregnant again so that you can heal both physically and emotionally. Talk with him or her about when the best time would be for you to attempt pregnancy after a miscarriage.
RECURRENT PREGNANCY LOSS
Recurrent pregnancy loss is the consecutive loss of three or more pregnancies in the first trimester or very early in the second trimester. As many as 1 couple in 20 experiences two pregnancy losses in a row. Up to 1 in 100 has three or more consecutive losses. Losses after the first weeks of the second trimester are much less common.
In the rare circumstance where more than two miscarriages have occurred, a specific cause can sometimes be identified and treated. Possible causes include:
Chromosomal alterations. One of the parents may have a chromosomal makeup that’s altered, resulting in changes in the fetus that lead to a higher rate of miscarriage. This problem could be addressed with donor sperm or donor egg procedures.
Problems with the uterus or cervix. If the woman has an unusually shaped uterus or weakened cervix, it may lead to miscarriage. Surgery may be able to correct some problems with the uterus and cervix.
Blood-clotting problems. Some women are more likely to form blood clots, which can result in poor placental function and miscarriage. Testing can determine whether a woman carries anti-cardiolipin antibodies or anti-phospholipid antibodies or factor V Leiden, all of which may cause miscarriage through increased blood clotting. A variety of approaches may be used to reduce the risk of miscarriage.
Other factors have been suggested as causes of recurrent miscarriages. They include progesterone deficiency in early pregnancy, problems with implantation of the placenta and a variety of infections. However, there’s no firm evidence that treating these problems affects the outcome of subsequent pregnancies. Often, no cause for the pregnancy losses can be found.
Don’t give up hope. Even if you’ve had repeated miscarriages, you still have a good chance to have a successful pregnancy. This is true even if the causes of the past losses cannot be found. Future pregnancies may need early attention, so talk to your care provider about special care you may need as your baby develops.
ECTOPIC PREGNANCY
An ectopic, or tubal, pregnancy is one in which the fertilized egg attaches itself in a place other than inside the uterus. The vast majority of ectopic pregnancies occur in a fallopian tube. They can also occur in the abdomen, ovary or cervix. Because the fallopian tube is too narrow to hold a growing baby, ectopic pregnancies can’t proceed normally. Eventually, the walls of the fallopian tube stretch and burst, putting the woman in danger of life-threatening blood loss.
There are strong associations between fallopian tube abnormalities and ectopic pregnancy. Factors known to increase the risk of tubal pregnancy include:
An infection or inflammation of the tube that’s caused it to become partly or entirely blocked
Previous surgery in the pelvic area or on the fallopian tubes
A condition called endometriosis, in which the tissue that normally lines the uterus is found outside the uterus, causing blockage of a fallopian tube
An abnormality in a fallopian tube’s shape
The major risk factor for ectopic pregnancy is pelvic inflammatory disease (PID), which is an infection of the uterus, fallopian tubes or ovaries. The risk of ectopic pregnancy is also higher in women who’ve had any of the following:
A previous ectopic pregnancy
Surgery on a fallopian tube
Infertility problems
A medication to stimulate ovulation
Pregnancy after a tubal ligation
Signs and symptoms At first, an ectopic pregnancy may seem like a normal pregnancy. Early signs and symptoms are the same as those of any pregnancy — a missed period, breast tenderness, fatigue and nausea.
Pain is generally the first sign of an ectopic pregnancy, but abnormal bleeding usually is present, too. You may feel sharp, stabbing pain in your pelvis, abdomen or even your shoulder and neck. It may come and go, or get better and worse. Other warning signs of ectopic pregnancy include gastrointestinal symptoms, dizziness and lightheadedness. If you experience any of these signs or symptoms, contact your care provider right away. There may be other possible causes for the signs and symptoms, but your care provider may first want to rule out an ectopic pregnancy.
Treatment If your care provider suspects an ectopic pregnancy, he or she will likely perform a pelvic exam to locate the pain, tenderness or a mass. Unless your condition is obvious or you’re clearly in an emergency situation, lab tests and ultrasound may be used to confirm the diagnosis.
The fertilized egg must be removed to prevent rupture of the tube and other complications. Small ectopic pregnancies may be treated with the medication methotrexate, which is highly toxic to placental tissue and causes the egg to stop developing. In many cases, surgery is required. A small incision is made in the lower abdomen and a long, thin instrument inserted into the pelvic area to remove the mass.
After treatment, your doctor will likely want to recheck your level of a pregnancy hormone called human chorionic gonadotropin (HCG) until it reaches zero. If the level remains high, it could indicate the ectopic tissue wasn’t entirely removed, and you may need additional surgery or treatment with methotrexate.
On rare occasions, a care provider may recommend no treatment except observation to see if an ectopic pregnancy will end on its own, through spontaneous expulsion or absorption, before any damage is done to the fallopian tube.
Future pregnancies If you’ve had one ectopic pregnancy, you’re more likely to have another. Successful pregnancy after an ectopic pregnancy may still be possible. Even if one tube was injured or removed, an egg may be fertilized in the other fallopian tube before entering the uterus. If both tubes were injured or removed, in vitro fertilization may be an option.
In vitro fertilization involves retrieving mature eggs from a woman, fertilizing them with sperm in a laboratory and implanting the fertilized eggs in her uterus two days later.
If you’ve had an ectopic pregnancy, talk to your care provider before becoming pregnant again so that together you can work on the best strategy.
MOLAR PREGNANCY
Molar pregnancy occurs when the tiny, finger-like projections that attach the placenta to the uterine lining (chorionic villi) don’t develop properly. The result is an abnormal mass forming inside the uterus instead of a baby. This mass is a tumor of placental tissue, which arises from abnormal chromosomes in the fertilized ovum. Molar pregnancies are relatively rare.
Signs and symptoms The main sign of molar pregnancy is bleeding by the 12th week of pregnancy. Often, the uterus is much larger than expected, given the length of the pregnancy. Severe nausea and other problems of pregnancy are common. Molar pregnancies are diagnosed with an ultrasound examination.
Treatment A molar pregnancy is removed from the uterus using the D&C procedure. An anesthetic is given, then the cervix is dilated and the contents of the uterus gently removed by suction.
Once tissue from a molar pregnancy is removed, your care provider will likely want to monitor your levels of the pregnancy hormone HCG for an extended time. Occasionally, this tumor will take on a malignant character and the level of the hormone HCG will remain high or increase after the tumor has been removed. For this reason, your care provider will probably want to test your HCG level on a regular basis. If the abnormal cells of molar pregnancy become cancerous (malignant), they’ll need to be treated with chemotherapy. This is one of the greatest success stories in cancer medicine — with appropriate chemotherapy, these cancers are usually cured.
Women who’ve had a molar pregnancy are advised not to become pregnant again for at least a year. Once you’ve had a molar pregnancy, you’re at greater risk of a future molar pregnancy. However, chances are also good that future pregnancies will be normal.
CERVICAL INCOMPETENCE
Cervical incompetence is the medical term for a cervix that begins to thin and open before a pregnancy has reached full term. Instead of happening in response to uterine contractions, as in a normal pregnancy, the cervix thins and opens because its connective tissue can’t withstand the pressure of the growing uterus.
Cervical incompetence is relatively rare. However, it is responsible for some pregnancy losses, especially in the second trimester. You’re more likely to develop cervical incompetence if you’ve had a previous operation on your cervix or you have a damaged cervix due to a previous difficult delivery or a malformed cervix due to a birth defect.
Signs and symptoms Cervical incompetence occurs without pain, but it causes many of the other signs and symptoms of miscarriage and preterm labor. These include spotting or bleeding, vaginal discharge that’s bloody, thick or mucus-like, and a feeling of pressure or heaviness in your lower abdomen.
Treatment If you experience signs and symptoms, contact your care provider. If you develop cervical incompetence and it’s caught early, your care provider may be able to stitch your cervix shut, which may save your pregnancy. This procedure, called cerclage, is most successful if it’s performed before the 20th week of pregnancy.
If you’ve had a previous pregnancy loss due to cervical incompetence, you’ll probably have the cerclage procedure done early in subsequent pregnancies — at about 12 to 14 weeks, which is after the pregnancy is well established but before its weight is taxing the cervix.
COPING WITH PREGNANCY LOSS
In rare situations, a baby dies during the course of late pregnancy. This is known as an intrauterine fetal death, or stillbirth. When a baby dies at any stage but especially late in pregnancy, the loss is immense and the grief is hard to overcome. The baby that you’ve carried for many months, dreamed about and planned for is suddenly gone.
You may feel as if your world has come crashing down. Maybe you can’t even think of life continuing as normal. But there are some things you can do to make the future more bearable and to ease your pain. It may help you to:
Say goodbye to the baby Grieving is a vital step in accepting and recovering from your loss. But you may not be able to grieve for a baby you’ve never seen, held or named. It may be easier for you to deal with the death if it’s more real to you. You may feel better if you arrange a funeral or burial for the child.
Save a memento of the baby Experts say it helps to have a photo or memento from someone who has died so that you have a tangible reminder of him or her to cherish now and in the future. Ask well-intended family and friends not to clear out the baby’s nursery, if you want and need more time to process the loss.
Grieve Cry as often and for as long as you need to. Talk about your feelings and allow yourself to experience them fully. It’s best not to avoid the mourning process.
Seek support Lean on your partner, family and friends for support. Although nothing can banish the hurt you’re feeling, you may gain strength from others who love you and support you. You likely could benefit from professional counseling after the loss of a child or from joining a support group of parents who have experienced a loss.
You and your partner will likely wonder why you had to experience this loss. You will never have a satisfactory answer to that philosophical question, but it may help you to learn about the physical causes of the death of the baby so that you have some understanding of what happened. You may want to discuss the findings from the autopsy with your care provider, after the initial shock has passed. Knowing a cause of death or details of what transpired may help you better accept the loss.
TRYING AGAIN
A pregnancy loss can be an extremely difficult experience. You may feel as if your hopes for the future have been taken from you. These feelings can occur even if the pregnancy was only a few weeks along.
There’s no set of rules about what you will or will not feel after a pregnancy loss. You may even feel simply numb for a while. Allow yourself to have your feelings and try to work through them.
Grieving a pregnancy loss takes time. Some couples think that they must try to conceive again right away in order to fix the problem or replace the hurt. Unfortunately, it’s unlikely that a subsequent pregnancy will carry the same feelings of innocence and bliss. A pregnancy after a loss can be highly stressful because of anxiety and fear that something may go wrong.
Although a pregnancy loss can be extremely difficult, it doesn’t mean you won’t be able to have another baby. In most cases, your chances of having a normal, healthy pregnancy are still excellent, even if you’ve had more than one or two losses. Your decision on whether and when to try again rests on the type of pregnancy you had, as well as your physical and emotional recovery. There’s no perfect time to try to conceive again. In general, most care providers recommend waiting a few menstrual cycles before trying again. In some cases, you may wish to consult a specialist before attempting to conceive again.
Emotional recovery If you find yourself grieving deeply after a pregnancy loss, allow yourself the time to do so. Emotional recovery can, and usually does, take much longer than physical recovery.
Some people may wonder why you mourn for a child you’ve never known. But in many ways you may have already bonded with the baby growing inside you. You and your partner may have shared many moments imagining the days when you would hold your baby in your arms. The missed opportunity of watching your child grow and develop can be difficult to accept. Even if no embryo was ever present, you will still grieve when your dreams and expectations were to have a baby. Grieving is the process of letting go of the emotional attachment you’ve developed.
Stages of grief No one goes through the grieving process the same way, but certain emotional stages are common to people who’ve had an important loss.
Shock and denial. Immediately after a traumatic event, people often feel numb and devoid of emotion. This is normal and doesn’t mean you’re uncaring. As reality sets in, these feelings often change.
Guilt and anger. After a pregnancy loss, you may be tempted to blame yourself for what has happened. But a pregnancy loss is rarely preventable. It’s highly unlikely that anything you did or didn’t do contributed to the pregnancy loss. You may also feel angry — with yourself, family, friends or simply with the circumstances. This is normal and to be expected. It may help to just let yourself be angry for a while.
Depression and despair. Depression isn’t always easy to recognize. You may find that you feel profoundly tired or that you lose interest in things you used to enjoy. Your appetite or sleeping patterns may change. Or you may find yourself crying over things that might otherwise seem minor.
Acceptance. Although you may not think this now, eventually, you’ll come to terms with your loss. This doesn’t mean you’ll be free from hurt, but you will find that it becomes easier to function.
These stages have no timetable. Some may take longer than others. Even after you’ve come to accept your loss, feelings of sorrow and pain may recur on an important date. During these times, the loss may feel fresh in your mind.
If you find that your feelings are so overwhelming that you can’t function or that they make you hostile or violent or interfere with your relationships with loved ones, talk with your care provider or seek the help of a mental health professional. He or she can help you deal with some of the issues you’re facing.
You and your partner may deal with a pregnancy loss in different ways. It may not always be easy to recognize that the other person is hurting. You may wish to talk things out, and your partner may prefer to stay silent. In addition, one may feel the need to move on before the other is ready.
Now more than ever you need to rely on each other for support. Try to listen and respond to each other while accepting the other person’s feelings. You may wish to consider seeing a counselor or therapist for help in expressing your emotions and expectations in more neutral territory.
YOUR PARTNER
You and your partner may deal with a pregnancy loss in different ways. It may not always be easy to recognize that the other person is hurting. You may wish to talk things out, and your partner may prefer to stay silent. In addition, one may feel the need to move on before the other is ready.
Now more than ever you need to rely on each other for support. Try to listen and respond to each other while accepting the other person’s feelings. You may wish to consider seeing a counselor or therapist for help in expressing your emotions and expectations in more neutral territory.
Physical recovery How long it takes to recover physically from a pregnancy loss often depends on the type of loss.
Miscarriage Physically speaking, it often takes only a few days for a woman to recover from a miscarriage. It usually takes four to six weeks after a miscarriage before your period comes back. It’s possible to conceive in those weeks between the miscarriage and your first menstrual cycle, but it’s generally not recommended. During this time, you may wish to use a barrier form of birth control, such as a condom or diaphragm.
If you and your partner feel ready to become pregnant again, there are several issues to consider. Before conceiving, talk to your care provider about your plans. He or she can help you come up with a strategy that will optimize your chances of a healthy pregnancy and delivery. If you had a single miscarriage, your chances of a subsequent healthy pregnancy are virtually the same as someone who has never had a miscarriage. Your care provider may suggest that you wait longer or have additional testing or monitoring if you’ve had recurrent miscarriages.
Ectopic pregnancy Your chances of having a successful pregnancy outcome may be a bit lower after having had an ectopic pregnancy, but they’re still good — between 60 and 80 percent if you have both fallopian tubes. Even if one fallopian tube has been removed, you still have more than a 40 percent chance of having a successful pregnancy outcome. But your chances of having another ectopic pregnancy increase — around 15 percent — so your care provider should monitor you closely the next time you conceive.
Molar pregnancy After a molar pregnancy, there’s a slight risk of further abnormal tissue growth. These growths are usually noncancerous (benign), but in rare cases they may be cancerous (malignant). This tissue growth is usually marked by high levels of the pregnancy hormone human chorionic gonadotropin (HCG). It’s important that you not become pregnant for a full year because the rising levels of HCG that occur with conception may be confused with recurrent disease. The risk that a molar pregnancy will develop in a future pregnancy is between 1 and 2 percent. Your care provider may recommend that you undergo ultrasound early in your next pregnancy to make sure that the pregnancy is normal.
TIPS FOR FUTURE PREGNANCIES
Although it’s very unlikely that you can prevent a pregnancy loss, you can do things to give yourself the best chance for a healthy pregnancy. Here are some tips to consider:
Eat a healthy diet and exercise regularly.
Get your daily dose of folic acid, either in a supplement or multivitamin.
Get pre-conception and prenatal care.
Don’t smoke, drink alcohol or use illicit drugs while you are trying to conceive or are pregnant.
Get checked and, if necessary, treated for sexually transmitted infections.
Limit caffeine consumption.
Work with your care provider. Together you can keep yourself and your baby as healthy as possible.