Recurrent Miscarriages

Recurrent miscarriage — losing a pregnancy more than once — is a particular kind of grief, made worse by how often it is met with “try again” and nothing else.

Recurrent miscarriage is investigable. Not every cause can be found, and not
every cause that is found can be treated — but a proper investigation is
worthwhile, and it should be offered rather than requested. This page sets out
what is looked for, which tests earn their place, which do not, and what happens
in the next pregnancy.

On this page

• What counts as recurrent miscarriage
• Why miscarriages happen
• The causes worth looking for
• The tests we consider useful
• Tests and treatments we are cautious about
• What treatment can involve
• Care in the next pregnancy
• Common questions

What counts as recurrent miscarriage

Recurrent pregnancy loss is usually defined as two or more consecutive
miscarriages. Some guidelines still use three. The distinction matters less than
it used to, because most specialists will now investigate after two — especially
where the woman is older, where a pregnancy was lost later rather than very
early, or where a scan had already shown a heartbeat.

You do not have to wait for a third loss to ask for an assessment. If two
pregnancies have ended, that is reason enough.

Why miscarriages happen

The commonest single cause of early miscarriage is a chromosomal error in the
embryo — an error that occurred when the egg or sperm was formed, or at
fertilisation. These errors are random, are not inherited, and become more
frequent with maternal age.

This is difficult to hear and important to understand. It means that a
succession of early losses can happen to a couple with nothing wrong with either
of them, purely through chance. It also means that the search for a cause does
not always end in an answer — and that the absence of an answer is not a failure
of the investigation.

Nothing you did caused it. Not working, not exercising, not lifting something,
not a stressful week, not travelling. Patients ask this in almost every
consultation, so it is worth stating plainly.

The causes worth looking for

Chromosomal causes

In a small proportion of couples, one partner carries a balanced chromosomal
rearrangement — usually a translocation. They are entirely healthy, but their
eggs or sperm can carry unbalanced combinations. This is found with a
karyotype
test on both partners. Where the pregnancy tissue is available, testing it
can also show whether that particular loss was chromosomal.

Uterine causes

A uterine septum, submucous fibroids distorting the cavity, intrauterine
adhesions and endometrial polyps can all contribute, and several of them are
correctable. The cavity is assessed by ultrasound and, where indicated, by
hysteroscopy, which
allows the problem to be seen and treated in the same session.

Antiphospholipid syndrome and clotting disorders

Antiphospholipid syndrome is the most clearly established treatable cause of
recurrent miscarriage. It is diagnosed by blood tests — lupus anticoagulant,
anticardiolipin and anti-beta-2-glycoprotein antibodies — repeated after an
interval, because a single positive result is not enough. Where it is confirmed,
treatment in the next pregnancy is well defined.

Thyroid and metabolic causes

Poorly controlled thyroid disease, thyroid antibodies, poorly controlled
diabetes and significant insulin resistance are all associated with pregnancy
loss, and all are straightforward to test for and to manage. A thyroid assessment belongs
in every recurrent miscarriage workup.

Sperm factors

The male partner is too often left out of this investigation. Sperm carries
half the genetic material, and damage to that DNA is associated with pregnancy
loss. A semen analysis, and in selected couples a
sperm DNA
fragmentation test, are reasonable parts of the assessment.

When no cause is found

For a substantial share of couples, every test comes back normal. This is the
commonest outcome of a thorough investigation, and it is not the same as being
told nothing is wrong and sent away. Unexplained recurrent loss still merits
supportive care in the next pregnancy, and a plan.

The tests we consider useful

• Karyotype of both partners
• Antiphospholipid antibody screen, repeated after an interval
• Thyroid function and thyroid antibodies
• Blood sugar and, where relevant, an assessment of insulin resistance
• Pelvic ultrasound, with hysteroscopy where the cavity is in question
• Semen analysis, with DNA fragmentation testing in selected couples
• Genetic testing of pregnancy tissue, where it can be obtained

That is a short list, and deliberately so. A test is worth doing when the
result would change what happens next.

Tests and treatments we are cautious about

Recurrent miscarriage attracts more unproven testing than almost any other
area of fertility medicine, because couples who have lost pregnancies will
understandably try anything.

Jananam offers add-ons selectively rather than routinely, and recommends one
only where there is a reasonable clinical justification for that individual
patient. Two examples of what that means in practice:

• The ERA test. We used endometrial receptivity analysis in
  more than 750 patients and no longer offer it routinely, because in our
  experience it did not improve outcomes sufficiently to justify what it costs
  the patient in time, procedures and money. The full reasoning is set out in
  why
  we stopped offering the ERA test.
• Immune testing. It is reserved for a specific subgroup of
  patients with repeated implantation failure or recurrent miscarriage, rather
  than being applied to everyone. Where it is indicated, endometrial immune
  profiling and HLA testing may be used to guide treatment.

If you are offered a long list of tests after two losses, it is fair to ask of
each one: what would we do differently depending on the result?

What treatment can involve

Treatment follows the cause, where one is found.

• Antiphospholipid syndrome — low-dose aspirin and heparin
  in the next pregnancy, started early, under supervision.
• Thyroid or diabetes — optimised before conception rather
  than during pregnancy.
• Uterine abnormality — hysteroscopic correction of a
  septum, adhesions, a polyp or a submucous fibroid.
• Balanced translocation — genetic counselling, with
  PGT-SR
  discussed as one option alongside natural conception with antenatal testing.
• Sperm DNA damage — treating a varicocele where present,
  addressing infection, heat exposure and smoking, and shortening the abstinence
  interval.
• No cause found — close early monitoring, progesterone
  support where indicated, and dedicated supportive care.

For selected women with repeated implantation failure or recurrent pregnancy
loss, EMMA/ALICE testing of the endometrial microbiome may be recommended to
identify potentially harmful bacteria.

Care in the next pregnancy

The next pregnancy is frightening in a way that a first pregnancy never is.
Practical steps help: early confirmation of the pregnancy, an early scan, planned
review appointments rather than waiting for the standard antenatal calendar, and
a named person to call.

Dedicated supportive care in early pregnancy — frequent contact, early
scanning, and being taken seriously — is one of the few interventions that has
been consistently associated with better outcomes in unexplained recurrent loss.
It is not a consolation prize. Ask for it.

Common questions

After how many miscarriages should we be investigated?

Two consecutive losses is a reasonable point to ask for a full assessment,
particularly if you are over thirty-five, if a heartbeat had been seen, or if a
loss occurred after the first trimester. You do not need to reach three.

Did I do something to cause the miscarriage?

No. Working, exercising, lifting, travelling, stress and ordinary daily life
do not cause miscarriage. The commonest cause is a random chromosomal error in
the embryo, which is determined before you even know you are pregnant.

Should my husband be tested too?

Yes. A karyotype is done on both partners, and a semen analysis — with DNA
fragmentation testing in selected couples — is part of a complete assessment.
Recurrent miscarriage is not solely a woman’s investigation.

Does Jananam offer the ERA test for repeated implantation failure?

We do not offer it routinely. We used it in more than 750 patients and
concluded that it did not improve outcomes sufficiently to justify the additional
cycle, biopsy and expense it requires. The reasoning is published in full on our
ERA
test page.

All our tests were normal. What now?

This is the commonest result of a thorough investigation, and it is not the
end of the road. Many couples with unexplained recurrent loss go on to have a
successful pregnancy. What changes is the care around the next one: early
scanning, close monitoring and a plan agreed in advance.

Will IVF stop us from miscarrying?

Not by itself. IVF is not a treatment for recurrent miscarriage unless there
is a separate reason for it, such as a balanced translocation where embryo
testing is being considered, or an additional fertility problem. It should be
recommended for a reason you can state, not as a general upgrade.

The RCOG Green-top Guideline on recurrent miscarriage sets out the investigations that are worth doing, and ESHRE publishes the European equivalent.

Written and medically reviewed by Dr. Vani Sundarapandian, MD, DGO, FRCOG
(UK) — founder and Medical Director, Jananam Fertility Centre, Chennai.