Losing a pregnancy more than once is hard, and it is natural to want an explanation. Recurrent pregnancy loss is usually defined as two or more pregnancy losses before 20–24 weeks. It affects roughly 1–2% of couples trying to conceive, and the chance rises with the mother’s age and the number of previous losses.
A structured evaluation looks for the causes that can be treated - antiphospholipid syndrome, thyroid and sugar problems, uterine shape problems such as a septum, and chromosomal rearrangements in either partner. In about half of couples no single cause is found. Even then, the chance of a successful next pregnancy is good - around two in three in many studies - and supportive early-pregnancy care makes a real difference to how that pregnancy feels.
Dr. Devang Patel evaluates and treats recurrent miscarriage at Divine Women’s Hospital in Gota, Ahmedabad, combining the investigation, hysteroscopic surgery where needed, early reassurance scans and high-risk pregnancy care in one place. Consultations are in Gujarati, Hindi or English, and both partners are welcome.
What counts as recurrent pregnancy loss
A single miscarriage is common: around 10–15% of recognised pregnancies end this way, most often because of a chance chromosomal error in that pregnancy. It does not usually signal an underlying problem.
Losses are also described by timing. Most happen in the first trimester, before 12–13 weeks. Losses between 13 and 24 weeks (second-trimester or mid-trimester losses) are less common and more often have a specific cause, such as a weak cervix, infection, APLA or a uterine problem, so they are investigated after even a single episode.
Recurrent loss is different. Guidelines from ESHRE and others now suggest evaluation after two losses, including biochemical pregnancies (a positive test with no pregnancy seen on scan), because couples deserve answers and some causes are worth finding early. Older guidance used three losses, so definitions vary between reports.
Why it happens
Several causes are recognised. Some are clearly treatable, some are risk factors that can be improved, and for some the evidence is still uncertain.
| Cause | How common | What can be done |
|---|---|---|
| Chromosomal error in the pregnancy itself | Most single losses; fewer with each repeat loss | Testing the pregnancy tissue helps explain the loss |
| Antiphospholipid syndrome (APLA) | About 10–15% of women with recurrent loss | Low-dose aspirin plus heparin injections in the next pregnancy |
| Uterine septum or other shape problem | About 10–15% | Hysteroscopic septum resection in selected women |
| Balanced translocation in a partner | About 2–5% of couples | Genetic counselling; options include prenatal testing or PGT with IVF |
| Thyroid disease, uncontrolled diabetes | Variable | Correct before conceiving and monitor in pregnancy |
| Age, BMI, smoking, alcohol | Contributing factors | Lifestyle changes, healthy weight, stopping tobacco |
Who is at higher risk
- Women aged 35 and above, with a steeper rise after 40
- Those with three or more previous losses
- Women with PCOS, thyroid disease or poorly controlled diabetes
- A BMI below 18.5 or above 30
- Smoking, tobacco chewing or heavy caffeine intake by either partner
- A previous loss after 10 weeks or a previous stillbirth
How the evaluation is done
The evaluation is completed over one or two visits and a few blood tests, ideally before the next pregnancy. Some tests, such as the APLA profile, need repeating 12 weeks apart to confirm a positive result.
- Detailed history, including the week of each loss and what the scans showed
- Antiphospholipid antibodies: lupus anticoagulant, anticardiolipin and beta-2 glycoprotein I antibodies
- Thyroid function (TSH) with thyroid antibodies, fasting sugar or HbA1c
- 3D ultrasound to look at the shape of the uterine cavity, with hysteroscopy if a septum or adhesions are suspected
- Karyotype of both partners where indicated, or chromosomal analysis of tissue from a recent loss
- Review of previous pregnancy scans and pathology reports
If a loss happens again, ask whether the pregnancy tissue can be sent for chromosomal testing. A result can explain that loss and guide what is tested next.
Tests that are not routinely useful
Couples are sometimes offered long panels of tests, including NK cell testing, HLA typing, extensive thrombophilia screens and multiple infection screens such as TORCH. Current guidelines do not recommend these routinely, because the results do not reliably change treatment or outcome.
Focusing on tests that make a difference saves money and worry. If a specific history points towards one of these, it is discussed openly.
Similarly, a raised homocysteine or a single borderline antibody result is common and usually not significant on its own. Results are always interpreted against your history, and borderline APLA results are repeated before any long-term treatment is started, because heparin injections every day for nine months are a real commitment.
Treatment matched to the cause
For APLA, low-dose aspirin plus daily heparin injections from a positive pregnancy test substantially improves the live birth rate; this is covered in more detail on the APLA and lupus page. A uterine septum can be divided by hysteroscopy as a day-care procedure. Thyroid levels are brought into range before conception, and diabetes is brought under control.
Where a balanced translocation is found, genetic counselling explains the realistic chance of a healthy pregnancy, which is often better than couples expect, and the options for testing.
When a mid-trimester loss happened because the cervix opened without contractions, a cervical stitch (cerclage) at 12–14 weeks in the next pregnancy, or serial cervical length scans, may be advised. This is discussed in more detail on the preterm birth prevention page.
| Finding | Treatment | When it starts |
|---|---|---|
| APLA confirmed | Low-dose aspirin plus daily heparin injections | Aspirin before conception; heparin from the positive test |
| Uterine septum | Hysteroscopic resection | Before trying again, usually one to two cycles of healing |
| Hypothyroidism or raised TSH | Thyroxine to bring TSH into range | Before conception, with dose increased once pregnant |
| Diabetes | Diet, metformin or insulin to reach HbA1c targets | Before conception |
| Balanced translocation | Genetic counselling, prenatal testing or PGT with IVF | Before the next pregnancy |
| Previous mid-trimester loss with cervical weakness | Cerclage or cervical length surveillance | From 12–14 weeks |
When no cause is found
Unexplained recurrent loss is the most common outcome of a full evaluation, and it is not a dead end. Many couples go on to a successful pregnancy without any specific medicine. Studies consistently show that early, supportive care with easy access to scans is linked with better outcomes in this group.
Vaginal progesterone from the first sign of pregnancy may be offered to women who have had a previous miscarriage and now have bleeding in early pregnancy, based on trial evidence. Steroids, IVIG and routine heparin without APLA are not supported by current evidence for unexplained loss.
The next pregnancy
Early contact matters. You are asked to call as soon as the test is positive, so any treatment can start and a first reassurance scan can be booked at about 6–7 weeks, when the heartbeat is usually visible. Further scans every one to two weeks through the first trimester are offered if they help.
Before conception, folic acid 400 micrograms daily (or 5 mg if advised), a healthy weight, stopping tobacco in any form and limiting caffeine to about two cups of tea or coffee a day are simple steps that help.
Once the pregnancy passes the week of previous losses, care continues with the routine schedule, with extra attention to growth and BP where APLA or other conditions are present.
Emotional support and long-term health
Grief after miscarriage is real, whatever the week of loss, and it is often not acknowledged by others. Some couples find it helps to take time before trying again, even when there is no medical reason to wait.
Anxiety and low mood are common after repeated loss, for both partners. It helps to know who to call, to have scans booked rather than waiting, and to talk openly. Referral for counselling is available if you would find it useful.
Some causes, especially APLA, also matter outside pregnancy because they raise the risk of blood clots. Women with confirmed APLA are advised on long-term follow-up and on contraception choices that avoid oestrogen.
Your care, step by step
- Listening and historyEach previous loss is reviewed in detail, including the week, scan findings and any reports.
- Focused testsAPLA, thyroid, sugar, uterine imaging and chromosomal tests are arranged as indicated, without unnecessary panels.
- Results and planThe findings are explained together and a written plan for the next pregnancy is agreed.
- Treatment before conceptionHysteroscopy, thyroid or sugar correction, or genetic counselling is completed first where needed.
- Early pregnancy supportMedicines start at the positive test and early reassurance scans are booked in advance.
When to book a visit
- Two or more pregnancy losses, including biochemical pregnancies
- A loss after 10 weeks with a normal-looking baby on scan
- A previous stillbirth or very early preterm birth
- A known APLA, lupus or clotting history
- A previous scan suggesting a uterine septum or abnormal cavity
- You are pregnant again after recurrent loss and want early monitoring
Warning signs - get same-day care
- Heavy bleeding soaking a pad an hour, or passing large clots
- Severe one-sided lower abdominal pain or shoulder-tip pain in early pregnancy
- Fainting, dizziness or a racing heartbeat
- Fever or foul-smelling discharge after a miscarriage
- Pain or swelling in one leg, or breathlessness, particularly with APLA
Labour and emergency care are available 24 × 7. Call the hospital and come in directly.
Myths and facts
Myth: Miscarriage happens because of stress, lifting or travel.
Everyday activity, work, intercourse and normal stress do not cause miscarriage. Most losses are due to chromosomal errors.
Myth: After three losses, a successful pregnancy is unlikely.
Even after several unexplained losses, most couples eventually have a successful pregnancy.
Myth: More tests always give better answers.
Many popular tests, such as NK cells and TORCH panels, do not change treatment. A focused evaluation is more useful.
Myth: Heparin helps every woman with recurrent miscarriage.
Heparin clearly helps women with APLA. It has not been shown to help unexplained loss.
Frequently asked questions
How many miscarriages before testing is needed?
Evaluation is reasonable after two losses, and sooner if a loss happened after 10 weeks or you are over 35. Older guidance used three losses as the threshold.
Should both partners be tested?
Yes, for some tests. Chromosomal tests in particular are done for both partners when they are indicated. Lifestyle factors in the male partner, such as smoking, are also discussed.
When can we try again?
For most couples there is no medical need to wait more than one normal cycle, but it is sensible to complete the key tests and start any treatment before the next conception.
What is APLA and why does it cause miscarriage?
Antiphospholipid syndrome is an autoimmune condition where antibodies make blood more likely to clot and affect the placenta. It is confirmed by two positive tests 12 weeks apart and treated with aspirin and heparin in pregnancy.
Does progesterone prevent miscarriage?
Vaginal progesterone may help women with a previous miscarriage who have bleeding in a new pregnancy. It has not been shown to help all women with recurrent loss.
Is a TORCH test needed after miscarriage?
Not routinely. TORCH tests do not explain recurrent miscarriage and often cause confusion. They are done only when there is a specific reason.
Can a uterine septum cause repeated miscarriage?
Yes. A septum is a band of tissue dividing the cavity and is linked to miscarriage. It is identified on 3D ultrasound or hysteroscopy and can be divided as a day-care procedure in selected women.
What if all the reports are normal?
That is the most common result. It means no treatable cause was found, and the chance of a successful next pregnancy is still good, with supportive early care.
Should the miscarriage tissue be tested?
It is worth considering after a second or later loss. Chromosomal analysis of the tissue can explain that loss and help decide which further tests are needed.
Does the husband’s health affect miscarriage?
It can. A balanced translocation in the male partner is one recognised cause, and smoking, heavy alcohol and older paternal age have been linked to sperm DNA damage. Sperm DNA fragmentation testing is not routinely recommended, but lifestyle advice applies to both partners.