Fertility & IVF
Recurrent Pregnancy Loss: Causes, Testing and Treatment Options
Recurrent pregnancy loss (RPL) is defined by ASRM as two or more failed clinical pregnancies. An evaluation looks for causes like chromosome problems, differences in the shape of the uterus, antiphospholipid syndrome and hormonal conditions such as thyroid disease or diabetes. No cause is found in about half of cases, and many people with RPL still go on to have a healthy baby.
If you're reading this after a loss, first: it's not your fault. Most miscarriages happen for reasons no one could have prevented. Not the run, not the coffee, not the argument, not lifting your toddler.
"Do I have to wait for a third loss?"
No. People are still sometimes told to "keep trying" until a third miscarriage. ASRM recommends an evaluation after two. If you've had two losses and want answers, it's reasonable to ask for testing.
For perspective: ACOG estimates early pregnancy loss happens in about 10% of known pregnancies, and the risk rises with age. One miscarriage usually doesn't mean anything is wrong. Repeated losses are less common, which is why two is the point to look closer.
What the evaluation is actually like
The first visit is mostly talking. Your doctor will go through each pregnancy: how far along it was, whether a heartbeat was seen, how it ended, and whether tissue was tested. Before you go, gather what you can: dates, ultrasound reports, ER discharge papers, any lab results. It's hard to relive these details. Many people find it easier to write a simple timeline at home first and hand it over.
The testing usually happens over one or two menstrual cycles:
- Blood work, often several tubes in one visit
- An imaging test of the uterine cavity, often a saline sonogram: a thin catheter puts a little sterile saline into the uterus during a vaginal ultrasound. It causes cramping for a few minutes, a bit like period cramps.
- Karyotype blood tests for both partners
- For antiphospholipid antibodies, a repeat test at least 12 weeks later to confirm any positive result
The follow-up is where your doctor reviews everything and makes a plan for your next pregnancy. That plan often includes early ultrasounds and a clear number to call if bleeding starts.
Possible causes, and how they're tested
| Possible cause | What it is | How it's tested |
|---|---|---|
| Embryo chromosome problems | Random errors in the egg or sperm, more common with age | Testing of pregnancy tissue, when available |
| Parental chromosome rearrangement | A balanced translocation in one partner | Karyotype blood test for both partners |
| Uterine abnormalities | Septum, fibroids or polyps inside the cavity, scarring | Saline sonogram, 3D ultrasound, hysteroscopy or MRI |
| Antiphospholipid syndrome (APS) | Autoimmune condition that causes clotting | Lupus anticoagulant, anticardiolipin and anti-beta-2 glycoprotein I antibodies |
| Thyroid disease | Over- or underactive thyroid | TSH blood test |
| Diabetes | Poorly controlled blood sugar | Hemoglobin A1c or glucose test |
| High prolactin | Pituitary hormone imbalance | Prolactin blood test |
Chromosome problems. About half of first-trimester losses come from chromosome errors in the embryo. These are usually random and increase with egg age. When possible, testing tissue from a miscarriage shows whether a chromosome problem caused that loss.
In a small percentage of couples, one partner carries a balanced translocation, a rearrangement of chromosome pieces that doesn't affect their own health but can lead to unbalanced embryos. A genetic counselor can explain options, including IVF with embryo testing (PGT-SR). See our guide to embryo genetic testing.
Uterine factors. A uterine septum (a band of tissue dividing the uterus) is linked to pregnancy loss and can often be removed with hysteroscopic surgery, usually an outpatient procedure. Fibroids or polyps that bulge into the cavity, and scar tissue (Asherman syndrome), may also be treated.
Antiphospholipid syndrome. An autoimmune condition that can cause blood clots and pregnancy complications. Diagnosis requires positive antibody tests on two occasions at least 12 weeks apart. ACOG and ASRM support low-dose aspirin plus heparin during pregnancy for people with APS and recurrent loss. Heparin is a daily injection under the skin; your doctor decides the dose.
Tests you may see online but probably don't need
ASRM advises against routine testing for some popular but unproven causes:
- Most inherited clotting disorders (thrombophilias), unless you've had a blood clot yourself
- Natural killer cell testing and other immune panels
- Routine endometrial biopsy for "luteal phase defect"
Treatments based on these tests, like IVIG or steroids, aren't supported for routine use. If a clinic offers a long, expensive immune panel, it's fair to ask what evidence supports it.
Should you save tissue from a miscarriage?
If you have another loss, ask whether chromosome testing of the pregnancy tissue is possible. If the loss was caused by a random chromosome error, that can be reassuring and may spare you other tests. It isn't always possible, especially when a miscarriage happens at home. Ask your provider ahead of time how to collect and store tissue, so you're not trying to figure it out in the moment.
Treatment depends on what's found
- Septum or cavity problems: hysteroscopic surgery
- APS: aspirin and heparin during pregnancy
- Thyroid disease or diabetes: get them well controlled before trying again
- Balanced translocation: genetic counseling, then natural conception, IVF with PGT-SR or donor gametes
- Repeated chromosomal losses linked to age: talk about IVF with PGT-A or donor eggs
When no cause is found, the outlook is still often encouraging. Supportive care in early pregnancy, with early ultrasounds and a team you trust, has been linked with good outcomes in research. Some doctors also discuss progesterone for people with prior losses who have bleeding in early pregnancy, based on recent evidence. Ask whether it fits you.
Things you can control
You didn't cause your losses. These steps simply support a healthy next pregnancy:
- Stop smoking and avoid recreational drugs
- Keep caffeine moderate. ACOG says under 200 mg a day (roughly one 12-ounce coffee) doesn't appear to be a major factor in miscarriage.
- Avoid alcohol while trying to conceive
- Work toward a healthy weight
- Take a prenatal vitamin with folic acid
Grief is part of this
Repeated losses can bring grief, anxiety and depression, and the next pregnancy often feels more frightening than joyful at first. Many people say they couldn't relax until a certain week, or couldn't tell anyone. That's common. Support that helps:
- A therapist who specializes in reproductive loss
- Peer support groups, in person or online
- Asking your clinic about mental health resources
If you have thoughts of harming yourself, call or text 988 for the Suicide & Crisis Lifeline.
When to call your provider
Call your OB/GYN or fertility specialist if:
- You've had two or more pregnancy losses and want testing
- You're pregnant and have bleeding or cramping
- You're planning another pregnancy after a loss
Go to the emergency room for heavy bleeding (soaking more than two pads an hour for two hours), severe belly pain, fever or fainting.
Recurrent loss is evaluated by reproductive endocrinologists and, during pregnancy, often by maternal-fetal medicine specialists. You can browse fertility specialists in Queens and Manhattan.
Frequently asked questions
How many miscarriages before testing?
ASRM recommends an evaluation after two or more clinical pregnancy losses. Some doctors still use three as a threshold, but you can ask for testing after two.
What is the most common cause of miscarriage?
Chromosome problems in the embryo cause roughly half of first-trimester miscarriages. These usually happen by chance and become more common as the age of the egg increases.
Can you have a healthy pregnancy after recurrent miscarriage?
Yes. Many people with recurrent pregnancy loss go on to have a successful pregnancy, even when no cause is found. Your chances depend on your age and the number of previous losses.
Does stress cause miscarriage?
There's no good evidence that everyday stress, exercise, work or sex causes miscarriage. Most losses are caused by things outside your control.
Sources
- ASRM — Evaluation and treatment of recurrent pregnancy loss: a committee opinion
- ASRM — Definitions of infertility and recurrent pregnancy loss: a committee opinion
- ACOG — Early Pregnancy Loss (Practice Bulletin 200)
- ACOG — Antiphospholipid Syndrome (Practice Bulletin 132)
- ACOG — Repeated Miscarriages FAQ
This article is for general education and is not medical advice. It does not replace an evaluation by a licensed clinician who knows your history. If you think you have a medical emergency, call 911.