When do multiple miscarriages become Recurrent Pregnancy Loss and when should you seek treatment?
The modern definition of Recurrent Miscarriage or Recurrent Pregnancy Loss (RPL) is two or more miscarriages. In the past, it was thought that three was ‘too many’, but we feel that no one should have to go through three. Please come in if you are trying to conceive and have two miscarriages in a row. We believe no one should get to the point of asking themselves “why do i keep having miscarriages?”
The good news is that women with multiple miscarriages can have a healthy pregnancy, they may just need a little help from a fertility specialist like Overlake Reproductive Health.
Statistics dictate that chances of success are higher if you already have at least one child, before or in between your miscarriages, compared to women who have multiple miscarriages but no healthy delivery. But with professional fertility help, we can usually overcome the obstacles to achieve a healthy pregnancy and finally a baby.
At ORH, we do a thorough set of tests for miscarriage (see below) to find a cause in most couples who can get pregnant but keep miscarrying. Once properly diagnosed, appropriate treatments to fix and/or work around the issues will be implemented. And for couples not getting pregnant at all, we can usually overcome that too.
Causes of Multiple Miscarriages
There are many possible causes of multiple miscarriage, and it is not uncommon for some women to have multiple issues present. We recommend thorough testing be carried out after a pregnancy loss because the more information we can obtain about the issue(s) affecting you, the more closely we can tailor our treatment and improve your odds of a successful pregnancy. Below are some tips and advice on how to stay pregnant after multiple miscarriages.
If you can get pregnant but keep miscarrying, there are a few possible causes:
- Diminished Ovarian Reserve (low egg supply)
If less eggs are left in your ovaries, there will be more genetically abnormal eggs, and a greater chance of miscarriage. Age is a primary factor for egg quality. But diminished ovarian reserve can occur in young women as well. Risk factors for diminished ovarian reserve include smoking, ovarian surgery, STDs such as Chlamydia or Pelvic Inflammatory Disease, fallopian tube problems, endometriosis, or a family history of early menopause.
- Problems with the Uterus
Some women are born with a congenital uterine abnormality like a septate uterus, a dividing wall of tissue inside the uterus. Other problems with the uterus are acquired such as polyps of the lining of the uterus, and/or fibroid tumors (leiomyoma). Up to 25-50% of women have fibroids, but not all of them cause fertility issues or miscarriages – the number, size and location of the fibroids all matter. Scar tissue, especially from previous D & C procedures, can also be a problem. These uterine issues can generally be surgically corrected in a relatively quick outpatient procedure we can do inhouse.
- Autoimmune Conditions
Antiphospholipid antibodies and lupus anticoagulant are autoimmune conditions where a woman can make proteins that attack normal tissue in the body, including the baby’s placental tissue when pregnant. These increase the chances of miscarriage and, in some rare cases, can cause serious blood clots in the mother. We have treatments to prevent miscarriage in women with these antibodies.
Immune system-related thyroid problems are common in women with miscarriages and may just require thyroid medication to correct the issue. Serious autoimmune diseases like lupus also increase the risk of miscarriage but are not common.
- Blood Clotting Disorders
Most, but not all of these are genetically based. You may be born with genes that can increase your risk of both miscarriage and blood clots (like blood clots in the leg veins, deep vein thrombosis or DVT, which can spread to the lungs and be dangerous, especially in pregnancy). The most common blood clotting disorders don’t usually cause blood clots in the mom, but they do increase the risk of miscarriage. More serious blood clotting disorders exist, with a much higher chance of miscarriage or blood clots, but these are rare.
- Hormonal Problems
Thyroid problems or too much prolactin hormone may increase the risk of miscarriage, and untreated thyroid problems can increase the chance of OB complications. A prescription, which is a small pill taken before breakfast, is sometimes all that’s needed to carry a healthy baby to term.
- Chromosomal Abnormalities in Either Parent’s Genetic Makeup
Translocations, where part of one chromosome is swapped or joined with part of another, are rare. This occurs in approximately 3-5% of women with multiple miscarriages. But chromosomal abnormalities are common and the cause of many early miscarriages.
- Male Factor
Men that exhibit abnormal sperm quality (low counts, or poor morphology) tend to have more genetically abnormal sperm, increasing the chance for genetic abnormalities in the embryo. 50% of couples having difficulty conceiving are due to the male factor. That is why we recommend a semen analysis as one of the first steps in diagnostic treatment. People do not often realize that early miscarriages may be caused by genetic factors on the male side. These issues can be overcome through IUI sometimes or with IVF and PGT screening of embryos.
- Lifestyle Factors
Smoking, heavy drinking, and drug use also increase the chances of miscarriage as well as caffeine intake beyond 1 cup of regular brewed coffee a day. Extreme exercise and dieting can also be factors so we examine lifestyles of both partners initially.
Certain infections may increase miscarriages. Often treatment includes a round of antibiotics.
Treatments to stay pregnant after multiple miscarriages?
The treatments available to reduce your chance of another miscarriage will vary, depending on diagnosis.
Diminished ovarian reserve may respond well to fertility treatments using your own eggs, or you may need to go the route of egg donation, using a semen bank, or adopting an embryo. These options may not be ideal if, like most couples you desire a genetically related baby, but they are good options and during diagnosis we may determine to cross those bridges when we get there, meaning we will usually try a number of things first.
Treatment for autoimmune conditions or blood clotting disorders can lower your chance of another miscarriage by a large amount, but we can never get you down to a zero chance of miscarriage. For example, if you have a blood clotting disorder and we treat you with a ‘baby aspirin’ a day (81 mg low-dose aspirin) combined with blood thinner shots (such as Heparin or Low Molecular Weight Heparin), your next pregnancy could still be genetically abnormal and end up as a miscarriage. The shots can’t fix the genetic abnormality. But blood thinners, given as small shots under the skin in the stomach area that can be administered at home, can improve your chance of success.
Problems in the uterus may need surgery, which perform inhouse in an outpatient procedure. Patients will be home, recuperating in a few hours and sometimes this is all that is needed to carry the next pregnancy to term.
If one partner has a genetic rearrangement, we can do IVF (In Vitro Fertilization) with Preimplantation Genetic Testing (PGT) to select healthy embryos with the correct number of chromosomes. IVF with PGT testing gives coupes the best chance of success and we are experts at this procedure. We now perform genetic testing on all IVF embryos as our standard of care. When we know what to look for, we can avoid a number of genetic diseases and remove them from the family bloodline going forward.
Another option for a couple with a translocation is to use donor eggs or donor sperm instead of the partner’s eggs/sperm who is carrying the genetic abnormality. Adopting an embryo may also be a good option.
Should I do anything different next time I’m pregnant?
Yes, please come see a fertility specialist like ORH to receive extra care. We can check your progesterone levels and thyroid function early in pregnancy, with progesterone supplements or thyroid medication given if needed. Your pregnancy should be watched more closely with ultrasounds to check for normal growth and to find baby’s heartbeat in the first weeks of pregnancy.
If unfortunately, you do have another miscarriage, we can offer genetic testing to see if the pregnancy was genetically abnormal or not – e.g. if the baby had an extra chromosome (Down’s syndrome results in 47 instead of 46 chromosomes). We can tell if the genetic problem came from the egg or the sperm. Our hope is the sooner we see you, the faster we can get you to your healthy pregnancy and delivery.
Who should I see for miscarriage testing?
If you have experienced two or more miscarriages, we recommend you see a fertility specialist (Reproductive Endocrinology / Infertility doctor or REI MD). They have more tools at their disposable to accurately diagnose the root cause(s) behind your miscarriages than a regular OBGYN. If you are currently undergoing miscarriage testing it’s recommended that you do not to try to get pregnant until we know the results.
Diminished ovarian reserve (low egg supply) is just as common in women with multiple miscarriages as it is in women who are having trouble getting pregnant (infertility), and we perform a specialized ultrasound to look at the number of small follicles in your ovaries (antral follicle count or AFC) and the size of your ovaries, and blood tests including FSH, Antimullerian Hormone (AMH) and possibly a Clomid Challenge Test (CCT).
ORH has been helping people become parents for over 30 years. We do a thorough diagnostic evaluation on all of our patients and make a specialized treatment plan tailored to your needs. Our goal is to get our patients pregnant, with a viable healthy baby, in the least invasive way possible.
Miscarriages are a terrible thing to go through, so please reach out and get the help you deserve sooner than later.
Multiple Miscarriages FAQs
Can anyone recommend any treatment for coping after pregnancy loss?
Psychological support from friends and family is important. Counselors are available: Your OB or fertility clinic can give recommendations. Support is available from others with experience of infertility or pregnancy loss in online communities. Medically, see a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) to look for possible causes of miscarriage. Two losses is considered recurrent miscarriage not three losses. Many causes of miscarriage can be treated to reduce the chances of another pregnancy loss in your next pregnancy.
How soon are you allowed to try again after pregnancy loss?
After one miscarriage, it’s best to wait a month; there is some evidence of a higher chance of another loss in the first month. After two or more miscarriages (recurrent pregnancy loss) you should see a Reproductive Endocrinology and Infertility (REI) specialist to look for causes of recurrent miscarriage before you get pregnant again. After one loss you should see an REI if it took a year or more to conceive.
What is the treatment for recurrent pregnancy loss?
Recurrent pregnancy loss is defined as two or more miscarriages. Low dose ‘baby’ aspirin – 81mg a day plus heparin or enoxaparin shots may be needed for antiphospholipid antibodies or blood clotting disorders. Surgery is indicated for a uterine septum (a dividing wall inside the uterus) or for polyps or fibroids affecting the cavity of the uterus. We treat any thyroid or prolactin hormone issues. IVF may be needed for women with significantly diminished ovarian reserve. PGD (preimplantation genetic diagnosis) may be offered and is a good idea if either partner carries a chromosome translocation where part of a person’s DNA is switched between two chromosomes. See a Reproductive Endocrinology and Infertility (REI) specialist.
What are the risk factors for miscarriage?
There are many possible ‘risk factors’ for miscarriage but some women have no risk factors that can be identified ahead of time. Prior miscarriage(s), extremes of female age – early teens or 35 or over, smoking, uncontrolled diabetes or thyroid disease, a personal or family history of blood clots, or autoimmune diseases like lupus may all increase the risk of miscarriage. At least one previous child decreases the risk.
Is there something that could cause multiple miscarriages after already having one child?
Many possible causes of miscarriage exist. You have more chance of another success than multiple miscarriages with no child. With 2 or more miscarriages we look for low egg supply (diminished ovarian reserve), uterine problems like polyps or fibroids or an abnormally shaped uterus, abnormal antibodies in your blood and other immune system problems, blood clotting disorders, or hormonal problems. Rarely, infections may increase the risk of another miscarriage. Genetic tests can be performed on both partners if needed. See a Reproductive Endocrinology and Infertility (REI) specialist for testing and treatment to reduce the chances of another miscarriage.
What are some ways to prevent a miscarriage in women? No sex?
Sex when pregnant doesn’t increase the risk of miscarriage, but we usually advise women who are bleeding in the early part of pregnancy (a ‘threatened miscarriage’) not to have sex until the bleeding has stopped; if more bleeding follows after sex it just adds to the anxiety of the situation. A woman who’s had two or more miscarriages needs testing to look for a cause, by a Reproductive Endocrinology and Infertility or REI specialist if you’re trying again, or an OB doctor if you’re already pregnant.
Is a full term baby still possible after 2 abortions and 2 miscarriages?
You may still have a healthy baby: you’ve been pregnant 4 times already. Abortions rarely cause problems, but any surgical procedures (D&C) may cause scar tissue inside the uterus. After 2 miscarriages you should see a Fertility MD (Reproductive Endocrinology and Infertility or REI) to look for causes of recurrent miscarriage, including problems inside your uterus like polyps or fibroids or an abnormally shaped uterus, blood clotting disorders, immune system problems, or low egg supply (diminished ovarian reserve). Rarely, infections may increase the risk of another miscarriage.
If you have gone through the ordeal of multiple miscarriages and want help please get started here.