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Recurrent Miscarriage: Causes, Tests and What Can Be Done
Miscarriage is common. Around one in five recognised pregnancies ends this way, most in the first twelve weeks, and the great majority of women who have one go on to have a healthy baby next time. But when it happens twice, and certainly when it happens three times, something changes — both clinically and emotionally. Two or more losses meet the definition of recurrent miscarriage and justify investigation. This guide explains the real recurrent miscarriage causes, which tests are worth doing, which are not, and what treatment can realistically achieve.
When Investigation Is Justified
Most guidelines now recommend assessment after two consecutive losses rather than waiting for three, and earlier still if the woman is older, if a loss occurred after the first trimester, or if there is a relevant medical history. Waiting for a third loss before looking is difficult to justify when the tests are straightforward.
"Being told 'it's just bad luck, try again' after a second loss is not reassurance. It is a missed opportunity to look."
The Causes, and How Common They Are
Chromosomal abnormalities in the pregnancy
By far the largest single cause of early miscarriage. A chromosomally abnormal embryo cannot develop, and the pregnancy ends. This is a random event in most cases, becomes considerably more frequent with maternal age, and is the reason age is the strongest predictor of miscarriage risk. It is also, importantly, nobody's fault.
Parental chromosomal rearrangements
In a small percentage of couples, one partner carries a balanced translocation — their own chromosomes are rearranged but complete, so they are entirely healthy, but a proportion of their eggs or sperm carry an unbalanced set. A karyotype test on both partners identifies this.
Antiphospholipid syndrome
The most important treatable cause. An autoimmune condition in which antibodies promote clotting in the placental circulation. It is diagnosed by specific blood tests repeated at least twelve weeks apart, and treatment with low-dose aspirin and heparin substantially improves live birth rates.
Uterine abnormalities
A uterine septum, submucous fibroids, endometrial polyps and intrauterine adhesions can all interfere with implantation or placental development. Most are correctable through hysteroscopic surgery via our minimally invasive surgery service. A cervix that opens too early causes second-trimester loss and is managed differently, sometimes with a cervical stitch.
Endocrine and metabolic causes
- Uncontrolled thyroid disease, and thyroid antibodies even with normal function — see thyroid symptoms in women
- Poorly controlled diabetes, particularly around conception
- Polycystic ovary syndrome with marked insulin resistance — see PCOS and fertility
- Raised prolactin
- Obesity, which independently raises miscarriage risk
Male factor
Increasingly recognised. High sperm DNA fragmentation is associated with recurrent loss, and advancing paternal age contributes. This is covered in male infertility and low sperm count.
Infection and other factors
Chronic endometritis, a low-grade inflammation of the uterine lining, is treatable with antibiotics once identified. Smoking, heavy alcohol intake, high caffeine consumption and significant environmental exposures all contribute.
Tests That Are Worth Doing
| Test | What it looks for |
|---|---|
| Antiphospholipid antibodies | Lupus anticoagulant, anticardiolipin and anti-beta-2 glycoprotein, repeated 12 weeks apart |
| Thyroid function and thyroid antibodies | Hypothyroidism and autoimmune thyroid disease |
| Blood sugar and HbA1c | Undiagnosed or poorly controlled diabetes |
| Pelvic ultrasound, ideally 3D | Uterine shape, fibroids, polyps, ovarian appearance |
| Hysteroscopy | Direct view of the cavity for septum, adhesions or polyps |
| Karyotype of both partners | Balanced translocations |
| Tissue karyotype from the miscarriage | Whether that loss was chromosomally abnormal — highly informative when available |
| Vitamin D, haemoglobin, ferritin | Correctable deficiencies |
| Sperm DNA fragmentation | Male factor contribution, in selected couples |
Treatment: What Actually Helps
Where a cause is found
- Antiphospholipid syndrome: low-dose aspirin plus heparin from early pregnancy, which meaningfully improves live birth rates.
- Thyroid disease: thyroxine to bring TSH into the pregnancy target range, with the dose usually needing to rise once pregnant.
- Diabetes: tight control before conception, not after.
- Uterine septum, polyps, submucous fibroids or adhesions: hysteroscopic correction.
- Cervical weakness: monitoring of cervical length, and a cervical stitch in selected cases.
- Balanced translocation: genetic counselling, with the option of IVF and preimplantation genetic testing to select unaffected embryos. See embryo freezing and frozen transfer, since tested embryos are frozen while results are awaited.
- Chronic endometritis: a course of appropriate antibiotics.
Where no cause is found
The evidence-based answer is supportive care in a dedicated early pregnancy setting: early confirmation of pregnancy, reassurance scans, close contact with a familiar team, and treatment of any correctable general factor. This approach alone is associated with markedly better outcomes, and most couples with unexplained recurrent loss eventually have a healthy baby.
What both partners should do
- Stop smoking completely, both of you.
- Stop or minimise alcohol, and limit caffeine.
- Move towards a healthy weight before the next pregnancy.
- Take folic acid from before conception.
- Correct vitamin D and anaemia.
- Book early in the next pregnancy — see what happens at the first antenatal visit.
The Part That Is Not Medical
Recurrent pregnancy loss is a bereavement, repeated, and it is frequently treated as though it were a minor medical event. Grief, anxiety in a subsequent pregnancy, guilt and strain within a relationship are all normal responses and none of them are a sign of weakness. Partners often grieve differently and at different speeds, which can feel isolating for both.
Ask for support rather than waiting to be offered it. Our psychiatry and mental health service provides confidential counselling, and our guide to stress management techniques offers practical starting points.
Getting Assessed in Ambikapur
If you have had two or more pregnancy losses, ask for an assessment rather than being told to simply try again. Our obstetrics and gynaecology department investigates recurrent miscarriage and runs a high-risk pregnancy service for the pregnancy that follows, supported by our IVF and fertility centre where genetic testing of embryos is indicated. Related reading includes female infertility causes and tests, pregnancy with pre-existing medical conditions and lower abdominal pain in women. Meet Dr. Rajshree Verma, Dr. Lata Goyal and Dr. Shradha Kinkar, see the full consultant team, browse all clinical departments, check our insurance and scheme empanelments, or book an appointment here.
"Half of these couples will never get an explanation. Most of them will still get a baby. Both of those things are true at once."
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