First trimester miscarriages are very common, but this doesn’t mean they’re any less difficult to deal with, or that the grief that comes with them isn’t real. Losing a baby at any stage of pregnancy is heartbreaking.
In the medical world, Recurrent Pregnancy Loss, (RPL), is when a woman experiences two or more pregnancy losses before 20 weeks of pregnancy. It's relatively uncommon, affecting about 5% of women / couples.
In July 2024, I was involved in writing the first Australasian Guidelines for Recurrent Pregnancy Loss (RPL) with the aim to streamline and expedite the evaluation process for affected couples.
It is important to note that a pregnancy ‘counts’ if it was confirmed on a positive pregnancy test and doesn’t require confirmation via an ultrasound. It used to be that these losses also had to be consecutive but that is no longer the case.
You can read the Australiasian Guidelines for Recurrent Pregnancy Loss below:
Miscarriages can happen for a variety of reasons, particularly during the first trimester, and it’s important to know that they are rarely caused by anything you did or didn’t do.
The causes can be broken down into:
The most common cause is chromosomal abnormalities in the embryo, which occurs at conception or during early cell division which is beyond anyone’s control. Identifying the specific cause often requires a thorough, multifactorial evaluation to determine the underlying reasons.
Some of these potential causes of recurrent miscarriage are:
The most common cause of miscarriage is an abnormal number of chromosomes in the embryo or fetus, known as aneuploidy, a risk that increases with maternal age.Testing the miscarriage tissue (products of conception), if available, can help confirm whether aneuploidy was the cause.
Another chromosomal factor is a balanced translocation in one of the parents. This occurs when parts of chromosomes swap places without any loss or gain of genetic material, which can result in chromosomally unbalanced embryos and an increased risk of miscarriage. A chromosome analysis (karyotype) can identify balanced translocations in parents.
For couples with balanced translocations, in vitro fertilisation (IVF) combined with preimplantation genetic testing (PGT) can improve the chances of a successful pregnancy. IVF with PGT may also benefit couples with normal chromosomes, increasing the likelihood of a successful pregnancy where losses have been due to aneuploidy.
Certain anatomical conditions can impact the uterus (womb) and contribute to miscarriage or Recurrent Pregnancy Loss. These include Müllerian anomalies (abnormal development of the female reproductive organs before birth), certain types of fibroids (intramural or submucosal), and scarring inside the uterus called intrauterine adhesions (or Asherman’s syndrome) which may develop after procedures such as dilatation and curettage.
Diagnosis typically involves specialised investigations such as hysteroscopy (a procedure that uses a camera inside the uterus), laparoscopy (a minimally invasive surgery using a camera inside the abdomen), 2D or 3D ultrasound, sonohysterogram (an ultrasound combined with fluid infusion into the uterus), or MRI (magnetic resonance imaging).
Research suggests that surgical removal of uterine septum (a type of Müllerian anomaly), submucosal fibroids, or intrauterine adhesions may improve pregnancy outcomes and increase chances of a live birth.
Certain thyroid disorders including hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), and autoimmune thyroid disease (where the immune system mistakenly attacks the thyroid gland), are linked to an increased risk of miscarriage.
Hypothyroidism can be effectively treated with thyroid medication (levothyroxine), reducing risk of miscarriage. Hyperthyroidism requires endocrinologist involvement, and anti-thyroid medications should be stopped upon pregnancy confirmation to avoid harming the embryo. Women who have thyroid antibodies but normal thyroid levels, should have their thyroid function monitored regularly during the first half of pregnancy and may need levothyroxine if levels become abnormal.
The link between high prolactin levels and Recurrent Pregnancy Loss is unclear. However, women should be assessed by their care provider as to whether they exhibit symptoms of elevated prolactin, with level checked if this is the case. Treating high prolactin levels may improve the chances of a successful pregnancy.
Miscarriage occurs slightly more often in women with PCOS, though the exact reasons are difficult to determine due to multiple factors associated with the condition. Managing PCOS in women with Recurrent Pregnancy Loss requires a personalised approach, which may include medication such as metformin, as well as lifestyle changes like a healthy diet and exercise. These interventions can improve pregnancy outcomes.
Maternal obesity is associated with a higher risk of Recurrent Pregnancy Loss. Women should be encouraged to achieve a normal body mass index (BMI) through diet and exercise, as weight loss can increase the likelihood of a successful pregnancy.
Conditions like diabetes, which affect blood sugar levels and metabolism, may be linked to Recurrent Pregnancy Loss, though the connection is unclear. Nonetheless, aiming for normal blood sugar levels is recommended.
For women with Recurrent Pregnancy Loss and those experiencing a threatened pregnancy loss (e.g., bleeding during early pregnancy), progesterone supplementation may be beneficial. While research is inconclusive about the benefits of progesterone for all women with Recurrent Pregnancy Loss, this treatment should be personalised based on individual circumstances.
Some blood clotting disorders are associated with Recurrent Pregnancy Loss, although not all are linked. The most common clotting disorder associated with RPL is antiphospholipid syndrome (APS), which is diagnosed based on symptoms and specific blood tests.
All women with RPL should be screened for APS. If diagnosed and the woman becomes pregnant, low-dose aspirin and heparin (a blood thinner) should be started. Unfortunately, these medications do not increase the changes of a successful pregnancy and live birth in women with other clotting disorders or in those with unexplained Recurrent Pregnancy Loss.
Immune factors may play a role in Recurrent Pregnancy Loss. It is hypothesised that certain antibodies could trigger an immune response in which the body mistakenly attacks the embryo. However, research in this area is still evolving. Poorly managed coeliac disease may also be linked to RPL.
Women experiencing symptoms like bloating, diarrhea, constipation, or stomach cramps, or who have a strong family history of celiac disease, should be tested for coeliac disease as part of the RPL workup. Unfortunately, many proposed immune-modifying treatments lack strong evidence of improving pregnancy outcomes.
Chronic endometritis, which is inflammation involving lining of the uterus, appears to be more common in women with Recurrent Pregnancy Loss. It is diagnosed by performing a biopsy on the lining of the uterus. Women diagnosed with chronic endometritis may benefit from antibiotics, to help resolve the inflammation and potentially increase the chances of a successful pregnancy and live birth.
Endometriosis is a condition where tissue similar to the lining of the uterus, grows outside of the uterus. The condition is associated with inflammation, and can affect egg quality and early pregnancy. There is some evidence linking it to Recurrent Pregnancy Loss. Adenomyosis is a related condition, whereby the lining of the uterus grows into the muscle of the uterus. It is less clear if adenomyosis is associated with RPL. At this stage, there is no evidence that treatments like surgery or medication for endometriosis are effective in reducing Recurrent Pregnancy Loss.
Research on environmental exposures such as chemicals in plastics, heavy metals, and caffeine have found some association with increased risk of miscarriage, although link with Recurrent Pregnancy Loss is inconclusive. Regardless, it is recommended to minimise unnecessary exposure to these substances.
Smoking is linked to infertility and miscarriage, therefore couples should stop smoking when trying to conceive. There is some research to suggest alcohol is linked with miscarriage, although it is uncertain if it is associated with RPL. Minimising alcohol when trying to conceive is encouraged.
It is acknowledged that experiencing Recurrent Pregnancy Loss is extremely stressful for a couple. It is unclear if this psychological stress can also affect RPL. Nonetheless, reducing stress is recommended as it may improve pregnancy outcomes. Care providers should adopt a multidisciplinary approach, potentially involving counselling, psychological support, and general practitioners to provide comprehensive care.
Factors such as obesity, smoking, alcohol use, and certain environmental or occupational exposures in men have been associated with Recurrent Pregnancy Loss. These lifestyle factors can contribute to DNA damage in sperm, which may increase the risk of RPL.
Therefore, a thorough assessment of the male partner’s lifestyle and health habits is imperative when evaluating a couple experiencing Recurrent Pregnancy Loss. Healthy lifestyle changes are encouraged in order to improve sperm quality. This includes quitting smoking, reducing alcohol, moderate exercise, and maintaining a healthy weight.
For men with significant sperm DNA damage, a testicular ultrasound may be helpful in identifying conditions such as a varicocele (enlarged scrotal veins). If a varicocele is detected, consulting a urologist (a doctor specialising in conditions of the urinary system) can provide further guidance and potential treatment options.
Some research suggests that taking antioxidant supplements may be a low-risk option to improve sperm quality and DNA. If lifestyle modifications and supplements do not improve sperm quality, in vitro fertilization (IVF) with advanced sperm selection techniques may be beneficial.
In some cases, the cause of Recurrent Pregnancy Loss is not always found. This can occur for 50-75% of couples being investigated for RPL. Once treatable causes have been addressed, care providers may discuss treatment options that may be helpful. These options can include progesterone supplementation, IVF with testing of embryos prior to transfer (PGT), and monitoring closely with supportive care.
After two or more miscarriages, it is advised to see a health care professional who can help evaluate and manage causes of Recurrent Pregnancy Loss. This will include a detailed personal history, physical examination, and any appropriate investigations.
Your path to treatment will depend on our findings during these initial investigations. I am proud to be able to provide continuity of care to my patients from the investigations right through to treatment and reproductive surgery should we need it.
Experiencing recurrent pregnancy loss can be an emotionally devastating and isolating journey, leaving you with more questions than answers. It’s important to remember that you are not alone, and with the right support, there is hope. Each loss is unique, and understanding the underlying causes can be the first step toward healing and moving forward.
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Recurrent Pregnancy Loss (RPL) is when a woman experiences two or more pregnancy losses before 20 weeks of pregnancy. It's relatively uncommon, affecting about 5% of women/ couples. After two miscarriages, it is recommended that women seek medical advice as some causes of RPL can be treated.
The causes of RPL can be broken down into the following groups: genetic (chromosome issues), issues with the structure or shape of the uterus (anatomical conditions), hormonal imbalances (endocrine disorders), blood clotting disorders (thrombophilia), conditions whereby the body’s immune system mistakenly attacks healthy cells and tissues (autoimmune conditions), infections, inflammatory conditions, environmental exposures, male causes, or unexplained.
After two or more miscarriages, it is advised to see a health care professional who can help evaluate and manage causes of RPL. This will include a detailed personal history, physical examination, and appropriate investigations tailored to the couple. If a cause is found, treating this may improve chances of a successful pregnancy.
The treatment options are diagnosis specific.
The good news is, the majority of women with recurrent pregnancy loss are able to achieve a healthy, on-going pregnancy with the right investigations and management.
Understanding the emotional journey couples endure when they have difficulty conceiving or recurrent pregnancy loss is essential to my approach.
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