Recurrent Pregnancy Loss

What is recurrent pregnancy loss?

Recurrent pregnancy loss (RPL), also called recurrent miscarriage, is defined by ESHRE as the loss of two or more pregnancies before 24 weeks. It affects around 1 to 2 percent of couples trying to conceive. Losses do not need to be consecutive. Going through repeated miscarriage is physically and emotionally hard, and couples deserve a careful, compassionate evaluation.

Symptoms and signs

• Vaginal bleeding or spotting in early pregnancy
• Cramping or lower abdominal pain
• Passing tissue or clots
• Loss of pregnancy symptoms, or no heartbeat seen on ultrasound

Some losses happen very early and are detected only by a falling pregnancy test (biochemical pregnancy).

Causes and risk factors

• Chromosomal abnormalities in the embryo, the most common cause of individual miscarriages, becoming more frequent with the woman's age
• A balanced chromosomal translocation in either partner
• Uterine problems such as a uterine septum, submucosal fibroids, polyps or adhesions
• Antiphospholipid syndrome (APS), an autoimmune condition that affects blood clotting
• Thyroid disease and poorly controlled diabetes
• Increasing maternal age and, to a lesser extent, paternal age
• Smoking, obesity and heavy alcohol or caffeine intake

In about half of couples, no clear cause is found after testing.

How it is diagnosed

• Detailed medical, pregnancy and family history
• Antiphospholipid antibody tests: lupus anticoagulant, anticardiolipin and anti-beta-2-glycoprotein I antibodies
• Thyroid function (TSH) and thyroid antibodies
• 3D transvaginal ultrasound, saline sonography or hysteroscopy to check the uterine cavity
• Genetic testing of pregnancy tissue where available
• Parental karyotyping in selected couples
• Blood sugar and other tests depending on history

Some tests, such as routine immune or natural killer cell testing, are not recommended by current guidelines because they have not been shown to help.

Treatment options

• Antiphospholipid syndrome: low-dose aspirin and heparin injections during pregnancy
• Thyroid problems: levothyroxine to correct thyroid levels
• Uterine problems: hysteroscopic surgery to remove polyps, submucosal fibroids, adhesions or, in selected cases, a septum
• Progesterone: may be offered to women with a history of miscarriage who have bleeding in early pregnancy
• Chromosomal translocation: genetic counselling, with options including natural conception or IVF with preimplantation genetic testing (PGT-SR)
• Lifestyle: stopping smoking, reaching a healthy weight and limiting alcohol and caffeine
• Supportive care: early pregnancy scans and emotional support, which are valuable even when no cause is found

Chances of pregnancy

Many couples with recurrent pregnancy loss, including those with no identified cause, go on to have a successful pregnancy. The chances fall with increasing maternal age and the number of previous losses. Your specialist can give a more personal estimate after testing, but no treatment can guarantee a live birth.

When to see a fertility specialist

See a specialist after two pregnancy losses, or after one loss if you are 35 or older, have had a second-trimester loss, or have a known medical condition such as APS or thyroid disease. Iswarya Fertility offers recurrent miscarriage evaluation at its 91+ centres.