What is Recurrent Miscarriage?
Recurrent pregnancy loss (RPL) is defined as the loss of two or more pregnancies before 24 weeks of gestation.
RPL affects approximately 1–2% of couples attempting to conceive. While a single miscarriage is often due to random chromosomal errors, repeated pregnancy losses may suggest an underlying medical or anatomical cause that requires detailed investigation.
Why Timely Evaluation Matters
Recurrent pregnancy loss presents both clinical and emotional challenges. However, with timely evaluation, recurrent miscarriage is often manageable, particularly when a specific underlying cause is identified. Early investigation can help uncover genetic, anatomical, hormonal, or immunologic factors and guide an appropriate, targeted treatment plan. This approach may reduce the risk of future pregnancy loss and improve reproductive outcomes.
What Causes Recurrent Miscarriage?
Chromosomal and Genetic Factors
A common cause of miscarriage is chromosomal abnormality in the embryo.. Human eggs have a propensity for meiotic errors that result in inappropriate numbers of chromosomes in the egg (aneuploidy) near the time of fertilization. These meiotic errors occur more frequently in women of advanced age. It is unusual for these numerical errors to revert back to normal numbers of chromosomes. Alternatively, embryos may undergo mitotic errors during cell divisions that lead to similar numerical errors in daughter cells (mosaicism). Mosaicism, while less common, is not particularly dependent on maternal age. Depending on the cell division during which this mosaicism occurs embryos may be overwhelmed by these errors or may be only slightly affected. In some cases, one or both partners may carry a balanced chromosomal rearrangement, such as a translocation, which does not affect the parent’s health may interfere with embryo viability. Embryos overwhelmed by cells with numerical chromosomal errors are unlikely to implant. When they do implant, most will not survive more than a few days beyond delivery. In most cases these implanted embryos with numerical chromosomal errors result in miscarriage.
Uterine Structural Abnormalities
The physical structure of the uterus can influence the ability to carry a pregnancy to term. Conditions such as a septate uterus, intrauterine adhesions, or large fibroids that distort the uterine cavity may prevent implantation or contribute to early miscarriage. These abnormalities are often detectable via imaging and, in many cases, correctable through surgical repair.
Thrombophilia and Immune Factors
Inherited or acquired clotting disorders, known as thrombophilias, have been associated with miscarriage in certain patients. The most clearly established immune-mediated cause is antiphospholipid syndrome (APS). APS is both diagnosable and treatable. Other immunologic conditions remain under investigation and are not routinely considered causative without additional clinical evidence.
Hormonal Imbalances
Endocrine disorders such as thyroid dysfunction, elevated prolactin levels, or insufficient progesterone production during the luteal phase may contribute to pregnancy loss. These are generally identified through bloodwork and respond well to medication when addressed early.
Infectious Causes and Lifestyle Factors
Chronic endometrial infections are less commonly responsible for RPL, but may be explored when clinically indicated. Lifestyle factors, including smoking, uncontrolled diabetes, and obesity, can also influence early pregnancy viability and are part of the overall assessment.
When No Cause Is Identified
Despite thorough evaluation, nearly half of all RPL cases remain unexplained. While this can be frustrating for patients, studies show that even without a specific diagnosis, many couples go on to have successful pregnancies with supportive care and close monitoring.
How Recurrent Miscarriage is Diagnosed
Diagnosis begins with a detailed review of your medical, reproductive, and family history. This first step helps define which diagnostic investigations are most appropriate in your case.
In many cases, both partners may undergo genetic evaluation, including karyotyping, to identify any chromosomal rearrangements that could affect embryo development. If IVF is being used, additional testing such as preimplantation genetic testing (PGT-A) may be considered to help select embryos with a normal chromosomal profile.
If you do suffer a miscarriage or a pregnancy lacking a beating heart, we can learn from the products of conception (POC). If we can collect the POC (tissue from a miscarriage or that is removed during a dilatation and curettage [D&C] procedure), it can help to identify whether numerical chromosomal errors contributed to the pregnancy loss.
The structure of the uterus is typically assessed using imaging techniques such as transvaginal ultrasound, saline infusion sonohysterography, or hysteroscopy. These methods help identify abnormalities that might interfere with implantation or early pregnancy.
Hormonal testing may include assessment of thyroid function, prolactin levels, and progesterone production during the luteal phase. When appropriate, screening for antiphospholipid antibodies or other clotting-related markers may be recommended, especially if there is a personal or family history of thrombosis or pregnancy complications.
Evaluation for infections is not routinely performed in all cases but may be considered when symptoms or clinical findings suggest a possible role.
How is Recurrent Miscarriage Treated?
Management of recurrent miscarriage is guided by the findings of the diagnostic evaluation. When chromosomal aneuploidy or a genetic translocation is identified as a contributing factor, we will probably advise the use of IVF with preimplantation genetic testing for aneuploidy (PGT-A). If chromosomal abnormalities are found in one of the partners, assisted reproductive technologies may be considered to improve outcomes. When anatomical abnormalities are identified, surgical procedures may be considered to improve conditions for embryo implantation. In cases involving confirmed clotting disorders or immune-related conditions, medical strategies may be used to support early placental development.
Hormonal disturbances such as those affecting thyroid function or the luteal phase are typically addressed to optimize the hormonal environment during early pregnancy.
For cases where no clear cause is identified, management focuses on individualized monitoring and supportive care. Many people in this group are able to achieve successful pregnancies without the need for intervention.
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