Recurrent Pregnancy Loss: Causes, Testing and Next Steps

Pregnancy loss and recurrent pregnancy loss

A miscarriage is the loss of a pregnancy before 20 weeks. It is common, and in most cases it is caused by a chromosomal change in the embryo that was random and nothing the parents did. After one loss, the chance of a healthy next pregnancy is high.

Recurrent pregnancy loss (RPL) is generally defined as two or more pregnancy losses. It affects a small share of couples, and evaluation can look for treatable causes. If you are grieving, you do not have to wait for a particular number of losses to ask for support or testing.

Possible causes

• Chromosomal changes in the embryo, which become more common with age, are the most frequent cause overall.
• Parental chromosome rearrangements, found in a small number of couples.
• Uterine factors, such as a septum, polyps, fibroids or scarring.
• Antiphospholipid syndrome, an autoimmune condition that raises clotting risk and is treatable.
• Endocrine factors, including thyroid disease and poorly controlled diabetes.
• Lifestyle and environmental factors, such as smoking and heavy alcohol use.

In around half of couples, no cause is identified despite testing.

What an evaluation includes

Your clinician may suggest a review of your history, a pelvic ultrasound or saline sonogram or hysteroscopy, blood tests (antiphospholipid antibodies, thyroid hormones and, in some cases, other hormone tests), and chromosome testing for both partners. Testing of the pregnancy tissue after a loss can show whether the embryo had a chromosomal change. See fertility testing.

Treatment

Treatment depends on the cause. Examples include surgery to correct a uterine septum, blood-thinning medication for antiphospholipid syndrome and treating thyroid disease. Some people use IVF with genetic testing of embryos (PGT-A) but evidence for improving live birth rates is mixed, so discuss this carefully with a specialist. Progesterone may be suggested in certain situations. See progesterone.

Emotional care

Loss can bring grief, guilt, anxiety and strain between partners. Many people also feel pressure to “stay positive.” You are entitled to time and support.

• Talk with your clinician about counseling.
• Consider peer support such as Share Pregnancy & Infant Loss Support or RESOLVE.
• See get help now if you feel overwhelmed or unsafe.

When to seek care urgently

Heavy bleeding, severe pain, fever or fainting during pregnancy need prompt medical attention. See urgent symptoms.

Defining the terms

Language around pregnancy loss can be confusing. A biochemical pregnancy is an early loss after a positive test but before an ultrasound can see a pregnancy. A clinical pregnancy loss is a loss after a pregnancy has been seen on ultrasound. Stillbirth refers to loss after 20 weeks. Professional definitions of recurrent pregnancy loss vary slightly between societies, with some counting two or more clinical losses and others three. In practice, many specialists will begin an evaluation after two losses, and earlier in some circumstances, such as older age.

The role of age

Most early losses are caused by chromosomal differences in the embryo, and these become more common as egg age increases. That is why the chance of loss rises with age, and why a person with several losses in their late 30s or 40s may have a different outlook from someone in their 20s. In many such cases the loss reflects bad luck in embryo genetics rather than a treatable problem, but evaluation can still rule out other causes.

Testing the pregnancy tissue

When possible, testing the tissue from a loss can show whether the embryo had a chromosomal difference. If it did, the loss is more likely to be random, which may be reassuring and may shift focus away from searching for another cause. If the embryo was chromosomally normal, further investigation of uterine, immune and hormonal factors becomes more important. Ask your clinician whether testing tissue is possible after a loss, because it often needs to be arranged at the time.

Treatments with and without evidence

Treatments with reasonably good evidence include surgical correction of a uterine septum, medication for antiphospholipid syndrome, and treatment of thyroid disease or poorly controlled diabetes. Evidence is weaker for many other interventions, including some immune therapies and supplements, which can be costly and carry risks. Be cautious about clinics that offer extensive panels or experimental treatments without clear evidence. Ask what study supports a treatment for your situation.

Supportive care also matters. Early and frequent monitoring in the next pregnancy, and kind, attentive care, may reduce anxiety even when it does not change the outcome.

Taking care of relationships

Partners may grieve differently and at different speeds. One may want to try again quickly while the other needs time. It helps to name this openly, to give each other permission to feel differently, and to seek counseling if tension builds. Friends and family may say hurtful things without meaning to. You can set limits on what you share and ask for the kind of support you need.

When to try again

There is no single right time. Medically, many clinicians suggest waiting until a period or two have passed, though recent evidence suggests that trying again soon after a miscarriage is not harmful in most cases. Emotionally, the right time is when you feel ready. Discuss timing with your clinician, especially if you have had surgery or complications.

Questions to ask

• Which tests do you recommend, and what could each result change in our plan?
• Can we test the tissue from a loss?
• Is there any treatment for my situation with good evidence?
• How early should I be monitored in the next pregnancy?
• Where can we find emotional support?

Next steps

Book a visit with your OB/GYN or a reproductive endocrinologist, bring a timeline of your pregnancies, and use the appointment questions planner. Read how to choose a fertility clinic.