Miscarriage, which is the spontaneous loss of a pregnancy before 20 weeks’ gestation, is extremely common. Less common is recurrent pregnancy loss (RPL), which occurs when a person experiences multiple miscarriages in a row—but it does affect 1–2 percent of women. Knowing how to seek out next steps—and knowing that there is hope—is an important step for those experiencing RPL.
It is estimated that 30–60 percent of overall pregnancies result in loss, with many miscarriages occurring before a woman even knows she is pregnant.
Miscarriages are also often referred to as pregnancy loss and, in medical terms, spontaneous abortion. It is estimated that 12–15 percent of clinically recognized pregnancies (meaning that the pregnancy is visualized on an ultrasound or pregnancy tissue was identified after the loss) end in miscarriage or pregnancy loss. It is estimated that 30–60 percent of overall pregnancies result in loss, with many miscarriages occurring before a woman even knows she is pregnant, and some research indicates that only 30 percent of conceptions result in a live birth.
Though pregnancy loss is a common experience, it can be extremely difficult and painful for individuals and couples who experience it. There are long-standing cultural practices around not speaking about pregnancy loss, and around the language used to describe it (the practice of not telling anyone you’re pregnant until you’ve made it to the end of the first trimester, for example, and the word “miscarriage” itself), that can make the experience even more challenging and isolating. On the medical side of things, the term “pregnancy loss” does not differentiate between miscarriage, which occurs before 20 weeks’ gestation, and stillbirth, which occurs after 20 weeks’ gestation.
What causes a miscarriage?
Most pregnancy losses before 20 weeks’ gestation are caused by:
· Chromosomal and genetic abnormalities
· Anatomical abnormalities of the uterus (e.g., structural issues, fibroids, scarring)
· Infections
· Blood disorders (such as clotting disorders)
· Endocrine/hormonal abnormalities (e.g., polycystic ovaries, diabetes, thyroid disorders)
· Abnormal immune responses/autoimmune disorders
· Cervical issues
· Male factors (increase in sperm DNA damage)
Despite all of these known causes, approximately 50–75 percent of miscarriages have no determinable cause. Randomly occurring chromosomal abnormalities of the embryo (i.e., not due to specific parental chromosomal abnormalities) are thought to be responsible for 50–80 percent of all first-trimester losses.
What is recurrent pregnancy loss (RPL)?
One or two miscarriages on their own are not indicative of future infertility, but any pregnancy loss can be physically and emotionally challenging. RPL is generally defined as having multiple miscarriages: three (sometimes two, depending on who you talk to) or more consecutive pregnancy losses prior to 20 weeks’ gestation, and it is estimated that RPL affects 1–2 percent of women.
Historically, evaluating the cause of RPL has not been recommended until after three losses. Some experts suggest it’s likely worth exploring potential causes after two losses. Previous pregnancy loss is the biggest risk factor for RPL. According to an article in the Journal of Human Reproductive Sciences, “the risk of miscarriage after two consecutive losses is 17% to 25% and the risk of miscarrying fourth pregnancy after three consecutive losses is between 25% and 46%.” Risk of multiple miscarriages also increases with increased maternal age, likely due to reduced egg quality leading to genetic abnormalities.
What can you do if you are experiencing RPL?
Working with your provider, there are evaluations and tests you can undergo to investigate the most common causes of RPL. Your providers will determine which evaluations make the most sense in your specific situation.
These evaluations can include:
· A full work-up (including medical and family history and physical examination)
· Evaluation of the uterus for any anomalies
· Testing for hormone levels
· Screening for antiphospholipid syndrome (APS) and other clotting disorders
· Analysis of sperm DNA
· Genetic testing for both parents
What does treatment look like?
Treatment for RPL is based on the underlying cause, if determined. For example, if a uterine anomaly is discovered, it’s possible that surgery can be performed. If chromosomal abnormalities are evident in either parent, genetic counseling will likely be recommended. Treating underlying infections, endocrine disorders, and autoimmune disorders can have a huge impact. For some of these disorders, recurrent pregnancy loss is the first recognized presentation of the disorder.
The good news? This support can make a huge difference in terms of having a successful pregnancy down the road.
Unfortunately, for over 50 percent of individuals experiencing multiple miscarriages, no cause is found. But, there is hope. According to UCLA Obstetrics and Gynecology, “no matter what the results of the work-up are, the chance for a successful future pregnancy is high: 77% if the work-up showed no abnormalities, and 71% if an abnormality was found.” In addition, one study found that “even after 4 consecutive losses a patient has a greater than 60% to 65% chance of carrying her next pregnancy to term.”
RPL can be psychologically devastating and traumatic for those experiencing it, and psychological support is an immensely important aspect of RPL care. According to the American Psychological Association, “one in 10 women exhibit signs of a diagnosable disorder such as anxiety, depression or post-traumatic stress disorder following a reproductive loss.” Having multiple miscarriages can be an extremely isolating and difficult experience, and support through counseling and therapy is strongly recommended for those experiencing RPL.
The good news? This support can make a huge difference in terms of having a successful pregnancy down the road. An article from Reviews in Obstetrics & Gynecology states, “The most effective therapy for patients with unexplained RPL is often the most simple: antenatal counseling and psychological support. These measures have been shown to have subsequent pregnancy success rates of 86% when compared with success rates of 33% in women provided with no additional antenatal care.”
So, while RPL can be a devastating experience, there is definitely hope. If you are experiencing RPL, you can discuss next steps with your provider, including possibly seeking out a provider who has significant experience caring for patients with RPL. Connecting with a counselor or therapist (especially one who is sensitive to and has experience with RPL) to provide psychological support can also be extremely helpful for you and/or your partner.
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