Recurrent miscarriage is the loss of three or more consecutive pregnancies of 13 weeks or less, with the same partner.
Miscarriages and early loss of pregnancy are so common that many obstetricians consider it a normal part of reproduction. That doesn’t make the loss easier but the fact that you were able to get pregnant at all should give you hope of having a baby in the future.
How many women have miscarriages?
Even after the confirmation of pregnancy, about 10-25% of all pregnancies end in miscarriage, according to the figures published by the American Pregnancy Association.
It also says that as many as 50-75% of all pregnancies end in first trimester miscarriage; a portion of those women are not even aware that they are pregnant when the loss occurs.
Henry Lerner, MD, clinical professor of obstetrics and gynecology at Harvard Medical School and author of Miscarriage: Why it Happens and How Best to Reduce Your Risks, said, “Since you got pregnant once, the odds are 80 percent that you will go on to have a healthy baby, and as many healthy babies after that as you want.”
About recurrent miscarriage
Also known as recurrent pregnancy loss (RPL), recurrent miscarriage is acknowledged when:
- You had 3 or more consecutive miscarriages (within 13 weeks of pregnancy), OR
- You had 2 late miscarriages (13 – 20 weeks of pregnancy)
1-2% of all pregnant women face multiple miscarriages due to different reasons.
Recurrent miscarriage causes
1. Chromosomal Abnormalities
60% of pregnancy losses are attributed to chromosomal abnormalities in the fetus.
There is 50% risk of miscarriage if you get pregnant after 40 because chances of aneuploidy (addition of extra chromosomes) are much higher. The risk of miscarriage is only around 10% in women under 35.
The egg quality of women starts to deteriorate as they start aging and that further increases the risk of miscarriage. Pre-implantation genetic screening (PGS) could be helpful, if:
- If you are experiencing multiple miscarriages due to chromosomal reasons
- If you are aware of a genetic problem in either of the partners
- If you go for natural pregnancy or IVF after 40 years of age
2. Anatomical factors
13% of recurrent miscarriage patients are noted to have anomalies in their uterine cavity—arcuate uterus, septate uterus, unicornuate or bicornuate uterus and a didelphys uterus.
A septum in the uterus (septate) is the most common abnormality in which the uterus is separated into two. A hysterosalpingogram can be used for diagnosis, which can further be confirmed with an MRI and a 3D sonogram.
A weak cervix also leads to second trimester miscarriages repeatedly or preterm deliveries.
3. Antiphospholipid syndrome
Upto 42% of recurrent miscarriage patients test positive for antiphospholipid antibodies.
Testing for these antibodies can be carried out in RPL patients but only after the anatomic, hormonal, and chromosomal causes have been ruled out.
If you test positive, Low doses aspirin and heparin are part of treatment regimen.
4. Immunologic problems
Reduced maternal immune tolerance towards the fetus is considered one of the causes of RPL but immunologic factor for recurrent miscarriages have not been clearly proven by research so far.
5. Hormonal and metabolic factors
- Hypothyroidism – Thyroid levels should be evaluated and TSH levels should be below 2.5mIU/L before trying for pregnancy.
- Diabetes – Highly elevated blood sugar can be associated with loss of pregnancy.
- PCOD – Excessive androgens as in PCOD/PCOS may cause loss of pregnancy.
- Increased prolactin – Elevated prolactin levels hamper follicular development and luteal function. This leads to reduction in progesterone levels in the luteal phase of the cycle.
- In patients with repeated miscarriage, progesterone supplementation can be given to improve chances.
- Thrombophilia (propensity for blood clots) – About 15% of recurrent miscarriages are attributed to this problem. Anti-coagulants may help, but more research is needed to establish their efficiency.
6. Lifestyle factors
Excessive consumption of alcohol, cigarettes and cocaine use have been reported to raise the risk of miscarriage.
Too much caffeine (over 3 cups a day) is also linked to miscarriages.
7. Unexplained repeated miscarriage
Over 50% of patients are unable to find the reason for repeated miscarriages. However the chances of a successful pregnancy after recurrent miscarriage in these cases are as high as 50-60%.
Recurrent miscarriage treatment options
In recurrent miscarriage tests, the Karyotype analysis (genetic or chromosomal make-up) of both partners is tested, but not all doctors choose to get these tests done because these problems are relatively rare.
Detecting the cause of recurrent miscarriage is important, so treatment can be tailored accordingly. The below treatments are considered:
- In women with anti-phospholipid syndrome or congenital thrombophilia, anticoagulants may increase chances of successful pregnancy.
- Certain chromosomal situations call for the usage of PGD testing with IVF to check the genetic makeup of embryos before implanting them in the uterus.
- The womb and its insides are also evaluated with an ultrasound, hysterosalpingogram X-ray, MRI, and/or hysteroscopy. These will help the doctor to determine the shape and size of the uterus, any abnormal growths, polyps, fibroids, uterine septum or scar tissue that may be interfering with pregnancy.
- If the problem is with the uterus, you can opt for surrogacy – an arrangement in which another woman agrees to carry your baby in her womb.
- For miscarriages due to thyroid or other endocrine problems, hormonal pills may be given and pregnancy is attempted only after the hormone levels are conducive.
- In cases of unexplained recurrent miscarriages, there is no universally acceptable recommendation or any RPL treatment. The chances to conceive after recurrent miscarriages of unknown reason are quite good, but every additional loss worsens the prognosis and increases psychological and physical risk to the mother.
- Consider hiring a surrogate mother if you are miscarrying every time and the doctors cannot point to any specific cause for that.
Recurrent miscarriage after IVF
Unsuccessful IVF or early loss of IVF pregnancy is usually attributed to poor genetic condition of the female egg.
The quality of female eggs worsens over time and the chances to get embryos with abnormal genetic makeup are high as you touch your 40s. If you have undergone IVF several times but miscarried early, it is probably due to embryo arrest.
Talk to your doctor and consider IVF with donor eggs or surrogacy.
We asked Dr. Tan Chong Seong, an experienced IVF specialist in Malaysia, and he recommends the below three options for repeated miscarriages:
- Thrombophilia screening
- Autoimmune screening
- Chromosomal screening
Other than this, we recommend sperm DNA fragmentation testing ,which is helpful in finding out the integrity of a sperm at the molecular level.
In 15% of cases, even sperm that passes the normal semen analysis, is actually has damaged DNA, which may be responsible for recurrent miscarriages.
We’ve had cases where the couple underwent around eight unsuccessful IVF cycles in over 10 years in several different countries, only to find out that the sperm DNA was responsible for the failure. A simple test could have saved them years of anguish and disappointment.
However, sperm DNA analysis is not advised for everyone. Consult with an experienced fertility expert to understand what may have caused your repeated miscarriages, before you spend any money on IVF.
If you are having trouble conceiving or have been facing recurrent miscarriages, get in touch to consult with one of our trusted fertility doctors and see if we can help you complete your family.