Women are often reluctant to talk about miscarriages, or spontaneous pregnancy losses. While one pregnancy loss can merit a visit to the doctor, two or more pregnancy losses should prompt a thorough examination for reproductive issues.

Major advancements in reproductive medicine have helped identify the causes of recurrent pregnancy loss. In the past, a woman might never know why she lost two or more pregnancies in a row, but today, an accurate diagnosis is possible in about 60 percent of cases. The most commonly identified causes include uterine problems, immunologic factors, hormonal disorders and genetic abnormalities.

At Yale Medicine, our Recurrent Pregnancy Loss Program is the only such dedicated program in the state. We bring together experts from an array of fields to evaluate and treat women in a comprehensive, compassionate manner. 

“I tell patients and couples I am seeing that we will do a thorough evaluation of issues that could predispose her to recurrent pregnancy loss,” says Amanda Kallen, MD, director of the Recurrent Pregnancy Loss Program and a reproductive endocrinologist and infertility specialist. “I reassure her that she will receive comprehensive, empathetic care, and that our focus is not just finding out what the issue may have been, but about supporting them through the process and the next pregnancy.” 

Recurrent pregnancy loss is two or more failed pregnancies. The definition of “loss” can include pregnancies that were confirmed via pregnancy test or confirmed in the clinic via ultrasound. 

About 15 to 20 percent of pregnancies end in miscarriage. Often, pregnancy loss is random, and does not mean there is any underlying genetic or reproductive issue. 

Approximately 2 percent of women experience two consecutive pregnancy losses, which could still be attributed to chance. However, about 0.5 percent of women experience a third consecutive loss, which might indicate a reproductive problem. Therefore, a full medical examination is recommended after two or more losses.

Abnormalities in a woman’s uterus can cause problems during pregnancy. Uterine abnormalities could include fibroids, endometrial polyps or intrauterine adhesions. The most common uterine abnormality leading to pregnancy loss can be attributed to a septated uterus, in which there is a wall of tissue dividing the uterine cavity.

Hormonal disorders, including uncontrolled diabetes, thyroid disease or polycystic ovary syndrome (an estrogen imbalance), could contribute to recurrent pregnancy loss. Because proper hormone levels are needed for successful pregnancy, elevated prolactin levels can also contribute.

In about 50 percent of cases, pregnancy loss can be attributed to an abnormal number of chromosomes in the embryo. These issues usually occur spontaneously at the time of conception, but may occasionally be inherited from parents.

There are other potential causes of recurrent pregnancy loss, including infections and sperm problems, although these are less well defined. Lifestyle factors such as smoking, drug use, caffeine and alcohol intake, toxin exposure and obesity should be addressed, as these can be contributing factors.

We offer couples who have experienced recurrent pregnancy loss a thorough and systematic analysis of each loss. We consider the timing of the loss and the visualization of developmental milestones prior to the loss (for example, fetal heartbeat on ultrasound). If available, we perform a genetic analysis of the pregnancy loss tissue (products of conception).

Couples are evaluated initially with a thorough history and physical examination followed by a series of diagnostic tests including blood work on both partners and evaluation of the uterus, usually with a specialized ultrasound study (sonohysterogram) to look for fibroids, scar tissue or polyps, that may compromise implantation.  

Additional evaluation may include tests to look for infection, endometrial biopsy to evaluate the endometrium, and analysis of the sperm. 

We also offer couples genetic testing for diseases that may silently impair their reproductive success. If tissue from the pregnancy loss can be obtained, we will perform genetic analysis on this to look for a genetic cause.

"We are starting to understand much more about the intricacies about the genetic aspects of pregnancy loss. When we look at the gene, it's like a road map and we can offer couples multiple levels of testing we didn't have even a few years ago," Dr. Kallen says. "And for the subset that remains unexplained, we can offer support, counseling, infertility treatment if needed and intensive monitoring of the next pregnancy."

After two or more pregnancy losses, we start a full medical evaluation, including a series of diagnostic tests as mentioned above. 

Because there are many potential underlying causes, we call on a team of experts across disciplines, including genetics (if a genetic cause is suspected), high-risk pregnancy specialists, reproductive endocrinology, reproductive immunology and pathology.

If the cause of recurrent loss is identified—for example, a polyp—it can be removed surgically. Or if a genetic link is identified, a woman could do in vitro fertilization and screen embryos for the genetic problem. Even without finding a cause, a woman's likelihood of having a baby is between 70 and 80 percent, says Dr. Kallen.

If we can't find anything wrong, we offer what we call tender-love-and-care protocol, or TLC, which involves weekly monitoring of the pregnancy, initially with blood work and then with ultrasounds every week.

We also offer assistance on lifestyle factors that might impact pregnancy, such as smoking, alcohol consumption, caffeine use, toxic exposures and obesity. Even with improved technology, sometimes recurrent pregnancy loss remains unexplained.

Even if a specific cause is never identified, the outlook is still very positive. Multiple studies show that the very practice of monitoring this condition and receiving emotional support can improve the odds of having a successful pregnancy.

“It doesn’t matter if the loss was after seven weeks or at full-term, it’s still a loss and something to grieve,” Dr. Kallen says. “I reassure patients that we are here for them every step of the way. In an ideal situation, we would have an answer for every patient. The unknown is scary. But when I tell them that in the majority of cases, the next pregnancy will be a normal, healthy one, that goes a long way.”

At Yale Medicine, we understand that recurrent pregnancy loss can put women and families under tremendous stress, both physical and emotional. 

Our Recurrent Pregnancy Loss Program aims to ease these factors by combining compassionate, patient-focused care with the latest diagnostic technology.

Working closely with patients to determine the root cause of specific difficulties is the first step towards achieving the dream of a healthy pregnancy. At Yale, we have the capabilities to offer a comprehensive, 360-degree evaluation of pregnancy losses including the latest in-depth genetic analysis for couples.