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Recurrent Miscarriage — Causes, Testing, and Treatment Options

A single early miscarriage is heartbreakingly common — roughly 15–20% of confirmed pregnancies end this way, most from random chromosomal errors that won’t repeat. Two or more consecutive losses, however, move the diagnosis from “unlucky” to “investigate.” Recurrent pregnancy loss (RPL) has identifiable causes in roughly half of cases — and most of those causes are treatable.

When Investigation Should Start

The traditional threshold is three consecutive losses. Most fertility specialists now begin investigation after two, particularly for women over 35 where time pressure makes waiting for a third loss both cruel and clinically wasteful. If you’ve had two losses at any gestational age, request a workup — don’t wait to be offered one.

The Causes — What Testing Looks For

Chromosomal (the most common)

50–60% of early miscarriages are caused by the embryo having the wrong number of chromosomes (aneuploidy). This can be random — and therefore unlikely to repeat — or it can reflect a parental chromosomal rearrangement (balanced translocation) that produces aneuploid embryos at high rates. Parental karyotyping (a blood test for both partners) identifies translocations. If found, IVF with PGT-SR (structural rearrangement testing) selects only chromosomally balanced embryos for transfer — dramatically reducing loss rates.

If miscarriage tissue was collected, products-of-conception (POC) testing can determine whether the lost pregnancy was chromosomally abnormal. A confirmed aneuploid loss is actually reassuring in a way — it means the loss was likely random, not caused by a persistent maternal condition.

Uterine Anatomy

A septate uterus (a wall of tissue partially dividing the cavity), fibroids distorting the cavity, or cervical insufficiency can all cause recurrent loss — often in the second trimester rather than the first. 3D ultrasound, saline sonogram, or hysteroscopy identify these. Surgical correction (septum resection, myomectomy, cervical cerclage) is often straightforward and significantly improves subsequent pregnancy outcomes.

Thrombophilia (Blood Clotting Disorders)

Antiphospholipid syndrome (APS) is the most important — antibodies that promote clotting in the tiny placental vessels, starving the embryo. Diagnosed by specific blood tests (anticardiolipin, lupus anticoagulant, anti-beta2-glycoprotein), confirmed by repeat testing 12 weeks later. Treatment with low-dose aspirin and heparin injections during pregnancy improves live birth rates from roughly 10% to 70–80% — one of the most dramatic treatment responses in all of reproductive medicine.

Inherited thrombophilias (Factor V Leiden, prothrombin mutation) are tested in some protocols, though their role in RPL is debated. Testing is reasonable; treatment decisions are nuanced and doctor-specific.

Hormonal

Thyroid disorders — even subclinical hypothyroidism — roughly double miscarriage risk. Thyroid guide. Uncontrolled diabetes significantly increases loss. Luteal phase defect (inadequate progesterone after ovulation) is controversial as a standalone diagnosis but progesterone supplementation in early pregnancy is widely used and safe.

PCOS associates with higher miscarriage rates, likely through insulin resistance and hormonal imbalance — management of the metabolic component (metformin, weight normalisation) may reduce risk. PCOS guide.

Immunological (Emerging)

Beyond APS, the role of natural killer (NK) cells and other immune markers in RPL is actively researched but not yet settled. Some clinics offer immune testing and treatments (intralipids, steroids, immunoglobulin); evidence is mixed, and most mainstream guidelines don’t yet recommend routine immune treatment outside of clinical trials. Discuss individually with your specialist — and be cautious about clinics that diagnose “immune rejection” as a routine explanation for unexplained RPL.

Unexplained (40–50% of cases)

Even after comprehensive testing, roughly half of RPL couples receive no clear diagnosis. The encouraging reality: the prognosis for unexplained RPL is actually better than explained RPL — 60–75% of these couples eventually achieve a successful pregnancy with supportive care (progesterone supplementation, early monitoring, emotional support) alone. Unexplained doesn’t mean untreatable; it means the next pregnancy has a genuinely good chance with close medical support.

The Testing Panel — What to Request

IVF with PGT as a Treatment for RPL

For couples with chromosomal causes — either parental translocation or age-related aneuploidy — IVF with preimplantation genetic testing offers the most direct intervention: only chromosomally normal embryos are transferred, reducing miscarriage rates to near the population baseline. It converts a repeated loss pattern into a controlled selection process. The cost is higher than natural conception, but measured against the cumulative physical, emotional, and financial cost of repeated losses, it’s often the most rational path.

Recurrent loss is one of fertility’s most painful experiences — and one of its most investigable. Don’t accept “just try again” without testing, and don’t assume a cause can’t be found. Female infertility guide · Free guidance from Pregology