Recurrent Pregnancy Loss: Understanding Causes, Diagnosis, and Treatment
Experiencing a miscarriage is one of the most difficult challenges a hopeful parent can face. When pregnancy loss happens repeatedly, the emotional and physical impact can feel overwhelming. At Tennessee Fertility Institute (TFI), we aim to provide clarity, compassion, and evidence-based care for those navigating this journey.
What Is Recurrent Pregnancy Loss (RPL)?
Recurrent Pregnancy Loss is defined as two or more consecutive clinical pregnancy losses before 20 weeks of gestation, confirmed by ultrasound or pathology. While a single miscarriage is relatively common, repeated losses are less frequent and often signal an underlying issue that requires investigation.
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Clinical vs. biochemical pregnancy loss: Clinical losses occur after confirmation by ultrasound, while biochemical losses are detected only by hormone levels.
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Primary vs. secondary RPL: Primary refers to losses without any prior live birth; secondary occurs after at least one live birth.
How Common Is It?
The American College of Obstetricians and Gynecologists (ACOG) estimates RPL affects approximately 1% of couples trying to conceive, while a single miscarriage occurs in about 15–25% of recognized pregnancies. Age does play a factor in recurrent pregnancy loss, with the risk increasing with maternal age. However, there is still hope. Many patients who experience RPL can still achieve a successful pregnancy with proper evaluation and treatment.
What Causes RPL?
Recurrent Pregnancy Loss can result from multiple overlapping factors. Here’s why each plays a role:
Genetic Factors
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Chromosomal abnormalities in embryos: Most early miscarriages occur because the embryo has an abnormal number of chromosomes (aneuploidy), which prevents normal development.
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Parental chromosomal rearrangements: If one partner carries a balanced translocation or inversion, it can lead to embryos with unbalanced genetic material, increasing miscarriage risk.
Anatomical Causes
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Uterine anomalies: A septum or scar tissue can reduce blood flow to the developing embryo or limit space for implantation, leading to pregnancy loss.
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Fibroids or polyps: These can distort the uterine cavity or interfere with implantation and placental development.
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Cervical insufficiency: A weak cervix may dilate too early in pregnancy, causing second-trimester losses.
Hormonal and Endocrine Disorders
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Thyroid dysfunction: Both hypothyroidism and hyperthyroidism can disrupt hormone balance critical for early pregnancy. You can learn more about the connection between thyroid health and fertility here.
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Uncontrolled diabetes: High blood sugar can impair embryo development and increase miscarriage risk.
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Luteal phase defects: Inadequate progesterone production can prevent proper implantation and early pregnancy support.
Immunologic and Hematologic Factors
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Antiphospholipid syndrome (APS): This autoimmune condition causes abnormal blood clotting, reducing blood flow to the placenta and leading to pregnancy loss.
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Other clotting disorders: Conditions like Factor V Leiden mutation can increase the risk of placental thrombosis.
Male Factor
Sperm DNA fragmentation: Damaged sperm DNA can compromise embryo quality and development, contributing to early loss even when fertilization occurs.
Lifestyle and Environmental Factors
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Smoking and alcohol intake: These can impair egg and sperm quality and affect uterine blood flow.
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Obesity: Associated with hormonal imbalances and inflammation that can interfere with implantation.
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Stress: Chronic stress may impact hormonal regulation and immune function, indirectly affecting pregnancy outcomes.
Unexplained Causes
In up to 50% of cases, no clear cause is found despite thorough evaluation. This does not mean treatment is impossible—many couples still achieve successful pregnancies with supportive care and monitoring.
How Is It Diagnosed?
A thorough evaluation for recurrent pregnancy loss involves multiple steps to identify potential causes:
Genetic Testing
Parental karyotyping: Detects chromosomal rearrangements like translocations or inversions that can lead to unbalanced embryos.
Imaging Studies
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Transvaginal ultrasound: Assesses uterine shape and detects fibroids or polyps.
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Saline sonogram or hysterosalpingogram (HSG): Provides a clearer view of the uterine cavity to identify septum, adhesions, or structural anomalies. You can learn more about this fertility test here.
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MRI (in select cases): Used for complex uterine anomalies.
Hormonal Assessment
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Thyroid function tests: Both hypo- and hyperthyroidism can disrupt pregnancy.
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Prolactin levels: Elevated prolactin can interfere with ovulation and implantation.
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Progesterone evaluation: Ensures adequate luteal phase support for early pregnancy.
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Diabetes screening: Poorly controlled blood sugar increases miscarriage risk.
Immunologic and Clotting Workup
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Antiphospholipid antibody testing: Identifies APS, a major cause of recurrent miscarriage.
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Thrombophilia panels: Detect inherited clotting disorders that can impair placental blood flow.
Male Factor Evaluation
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Semen analysis: Assesses sperm count and motility.
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DNA fragmentation testing: High fragmentation can compromise embryo development.
Lifestyle Review
Smoking, alcohol use, BMI, and stress levels are evaluated to identify modifiable risk factors.
Treatment Options
Treatment is highly individualized and depends on the underlying cause:
Surgical Correction
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Uterine septum removal: Improves implantation and reduces miscarriage risk.
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Fibroid or polyp removal: Restores normal uterine anatomy.
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Adhesion repair: Enhances uterine cavity integrity.
Medical Management
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Thyroid and diabetes control: Stabilizing these conditions reduces miscarriage risk.
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Progesterone supplementation: Supports early pregnancy in cases of luteal phase defect.
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Blood thinners: Low-dose aspirin or heparin for antiphospholipid syndrome or clotting disorders.
Genetic Solutions
IVF with Preimplantation Genetic Testing (PGT): Screens embryos for chromosomal abnormalities before transfer, reducing miscarriage risk.
Lifestyle Optimization
Smoking cessation, weight management, and stress reduction can improve overall fertility outcomes.
Supportive Care
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Close monitoring: Frequent ultrasounds and hormone checks in early pregnancy.
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Emotional support: Counseling and support groups to help manage grief and anxiety.
The Emotional Impact
RPL is not just a medical condition—it’s an emotional journey. Feelings of grief, guilt, and isolation are common. At TFI, we encourage patients to seek support through:
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Counseling services for individuals and couples.
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Support groups to connect with others who understand.
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Mind-body programs to reduce stress and promote healing.
You are not alone. With the right care and support, many couples go on to have successful pregnancies.
If you’ve experienced two or more pregnancy losses, schedule a consultation with our fertility specialists. We’ll work with you to uncover the cause and create a personalized plan for your path forward.