Why do you have recurrent miscarriages?

Recurrent miscarriage is the loss of three or more consecutive pregnancies of 13 weeks or less, with the same partner. If you’ve had recurrent miscarriages, it is possibly due to a hormonal imbalance, underlying genetic issues, or some uterine problems.

What is the most common reason for recurrent miscarriage?

Finding the possible reason for your recurrent pregnancy loss is crucial before deciding on any treatments.

Causes of recurrent early miscarriages (1^st trimester)

Chromosomal Abnormalities

Upto 65% of pregnancy losses are attributed to chromosomal abnormalities in the fetus (1).

There is 50% risk of miscarriage if you get pregnant after 40 because chances of aneuploidy (addition of extra chromosomes) are much higher. In women under 35, the risk of miscarriage is only around 10%, given all other factors are normal.

Uterine anomalies

13% of recurrent miscarriage patients are noted to have anomalies in their uterine cavity (2)—arcuate uterus, septate uterus, unicornuate or bicornuate uterus and a didelphys uterus.

Septate uterus is the most common abnormality in which the uterus is separated into two by a septum.

Incompetent cervix

28% of women with repeated second trimester miscarriages or preterm deliveries were found to have cervical insufficiency (3). It can normally be managed with cervical cerclage, in which the doctor will place stitches on the cervix to allow it to hold the pregnancy.

Dr. Leong, one of the most successful IVF specialists in Malaysia, explains below:

Causes of recurrent late miscarriages

Antiphospholipid syndrome

Antiphospholipid Syndrome (aPL) is an auto-immune disease responsible for recurrent miscarriages in around 10-15% of women (4). Miscarriage at 10 weeks or more of gestation is more strongly associated with aPL than are earlier pregnancy losses.

Testing for antiphospholipid 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.

Immunologic problems

Reduced maternal immune tolerance towards the fetus is considered one of the causes of repeated miscarriage. Autoantibodies including APA, anticardiolipin antibodies (ACA), and antinuclear antibodies (ANA) have been found to play a role in recurrent pregnancy loss (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 cause loss of pregnancy.

Endocrine issues – Excessive androgens as in PCOD/PCOS may cause repeated miscarriages.

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 supplements can be given to improve their chances of IVF success.

Thrombophilia (propensity for blood clots) 

About 15% of recurrent miscarriages are attributed to blood clotting. If confirmed, an anti-coagulant drug called Heparin will be used to prevent blood clots during your pregnancy (6).

Lifestyle factors

Excessive consumption of alcohol, cigarettes and cocaine use have been reported to raise the risk of miscarriage. Researchers found that excessive consumption of caffeine (by both men and women) even during pre-pregnancy could cause miscarriages (7).

Unexplained repeated miscarriage

In over 50% of patients, clinicians are unable to find the reason for multiple miscarriages. Unexplained recurrent miscarriages are extremely challenging and frustrating but you must know that the chances of a successful pregnancy in these cases are as high as 50-60%. They have excellent prognosis.

How common are recurrent miscarriages?

15-20% of all confirmed pregnancies end in miscarriage, according to the data available today (8).

75% of all miscarriages happen in the first 12 weeks and in many cases, the woman is not even aware that she’s pregnant.

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% of all women experience 3 or more miscarriages and around 5% of face 2 consecutive pregnancy losses due to different reasons.

Can I get pregnant after miscarriages?

If you have successfully achieved one pregnancy, you have 80 percent chances of having healthy pregnancies and babies in the future, said 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.’

However, if you’ve had two or more miscarriages and haven’t had any successful pregnancies, you must consult a fertility specialist ASAP.

Women who have had two or more miscarriages, have a 40% higher chance of having another miscarriage.

Tests for Recurrent Miscarriages

Recurrent miscarriage tests should be dependent upon an initial understanding of the possible cause.

If, for instance, the miscarriage happened due to a random genetic problem in the baby, you couldn’t have done much and chances are, you could go on to have a normal, healthy pregnancy without really needing any tests.

Scans and uterine investigations for miscarriages

• Hysterosalpingogram (HSG): This is an x-ray procedure that is done after injecting a dye into the uterus to see if there are any abnormalities that may be interfering with the pregnancy. This test is also done to test the patency of fallopian tubes.
• Transvaginal Ultrasound: To check for uterine, ovarian, and endometrial problems that may be causing recurrent miscarriages.
• Hysteroscopy: This is done via insertion of a thin telescopic instrument into the uterus to check the insides and get accurate pictures.  
• ERA test: Endometrial receptivity array is done by taking a biopsy from the uterine lining and checking it for any inconsistencies.

Blood tests for multiple miscarriages

• Lupus anticoagulant antibodies and Anticardiolipin antibodies: These are both marker for the antiphospholipid syndrome, which increases the chances of recurrent miscarriage.
• Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT): Both of these tests check for the clotting time of blood and any discrepancy may give an indication of hereditary thrombophilia.
• MTHFR Gene Mutation: This is known to interfere with folic acid absorption but the US CDC suggests that even if you have MTHFR C677T variant, consuming 400 mg of folic acid each day may help avoid neural tube defects.
• Thyroid Panel: Second-trimester miscarriage is sometimes associated with hypothyroidism. Thyroid tests are routinely performed in fertility work-up because abnormal thyroid levels also cause conception problems.
• Progesterone: Low progesterone levels could result in repeated miscarriages.
• Karyotype testing: This test is performed on both parents to check for genetic problems that cause risks to the pregnancy.

Genetic testing for miscarriages

• Sperm DNA fragmentation analysis: Even with normal semen analysis, there may be genetic problems in the sperm cell, which can be detected with sperm DNA fragmentation testing.
• Fetal Tissue Karyotyping: If you end up doing dilation and curettage after the miscarriage, a chromosomal test of the fetal tissue may be done to check for chromosomal anomalies.

It is important that consult with an experienced doctor to understand your situation, before doing any tests for multiple miscarriages.

What is the treatment for recurrent miscarriages?

Understanding the cause of recurrent miscarriage is important, so treatment can be tailored accordingly. The below treatments are considered:

1. Medication – In women with anti-phospholipid syndrome or congenital thrombophilia, anticoagulants may increase chances of successful pregnancy.
2. Genetic testing with IVF – Certain chromosomal situations call for the usage of PGT with IVF to check the genetic makeup of embryos before implanting them in the uterus.
3. Removal of uterine anomalies – After examination of the shape and size of the uterus, the doctor may check for and remove any abnormal growths, polyps, fibroids, uterine septum or scar tissue that may be interfering with pregnancy.
4. Hormonal pills – 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.
5. Surrogacy – 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.

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.

Does IVF help with recurrent miscarriage?

Depending upon the reason for multiple miscarriages, IVF may or may not be helpful.

Unsuccessful IVF or early loss of IVF pregnancy is often 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.

If eggs are the reason, you may talk to your doctor and consider IVF with donor eggs.

Dr. Tan Chong, a highly experienced IVF specialist in Malaysia, said that most commonly the below three investigations are done for repeated miscarriages: 

• Thrombophilia screening
• Autoimmune screening
• Chromosomal screening

Other than this, consider sperm DNA fragmentation testing which is helpful in finding out the integrity of a sperm at the molecular level. 

Sperm with damaged DNA may be responsible for recurrent miscarriages. 

Success story of IVF after 8 failed cycles

One of our clients—an Australian couple—underwent eight unsuccessful IVF cycles in over 10 years in several different countries, only to find out eventually that the sperm DNA was responsible for the failure. A simple test could have saved them years of anguish and disappointment. 

If you are having trouble conceiving or have been facing recurrent miscarriages, get in touch to consult with some of top fertility doctors on our panel and see if you can find a direction towards completing your family.

To consult with a specialist for recurrent miscarriage and your possible treatment options, get in touch. Online consultation starts $47 and IVF packages start $4,700.

Expert medical advice by: Dr. Tan Chong, IVF expert, Malaysia

Reviewd by: Dr. Meenakshi, PhD