- ATHENS OFFICE MED4WOMAN ATHENS
- VOLOS OFFICE MED4WOMAN VOLOS
Obstetrician-Gynecologist
PhD, University of Athens Medical School
Obstetrician-gynecologist Panagiotis Polyzos practices at the Institute of Life, the IVF Unit of IASO Maternity Hospital.
Pregnancy loss causes physical and emotional distress for couples, especially when it occurs repeatedly (recurrent miscarriages), and they certainly need support and psychological assistance from their environment (family, friends), as well as from the medical and nursing staff responsible for their care.
Spontaneous pregnancy loss is unfortunately a common phenomenon. Approximately 15% of clinically recognized pregnancies end in miscarriage, while a fairly large number of pregnancies are lost before they even become clinically detectable.
Historically, the term recurrent miscarriages refers to 2–3 consecutive pregnancy losses before 20 weeks, with a frequency of 1 in 300 pregnancies and affecting 1%–2% of women of reproductive age. Although the guideline suggests performing the relevant evaluation after the third miscarriage, in practice it is often necessary even after the first one, depending on the case.
The evaluation for recurrent miscarriages includes a detailed medical history, clinical and ultrasound examination, as well as chromosomal and specific histopathological examination of the miscarriage tissue, which may reveal findings associated with specific causes of miscarriages.
(e.g., immunological, thrombophilic) and guide further laboratory testing.
The etiology of recurrent miscarriages is usually multifactorial and includes genetic causes, anatomical abnormalities of the uterus, endocrine disorders, immune causes, thrombophilic disorders, infections, environmental factors, and unknown causes.
About 2% to 4% of recurrent miscarriages are linked to balanced chromosomal abnormalities in the parents and, depending on the specific diagnosis (karyotype of the couple), treatment includes in vitro fertilization with preimplantation genetic testing.
10% to 15% of recurrent miscarriages are linked to anatomical abnormalities of the uterus, which are diagnosed by hysterosalpingography and/or hysteroscopy while the treatment is surgical.
Approximately 17%–20% of recurrent miscarriages are associated with endocrine factors (e.g., diabetes mellitus, thyroid disorders, etc.), diagnosed through specific laboratory tests, and managed with medication.
Pregnancy represents an “immunological paradox,” since although the fetus is not genetically identical to the mother, she does not reject it but protects it through complex immunological mechanisms. Possible abnormalities in these mechanisms are related to single or recurrent miscarriages. Diagnosis is carried out with blood tests and specific examination of the miscarriage tissue, many of which are treatable, improving the live birth outcomes.
Thrombophilia is classified into inherited (15% of the population) and acquired, or a combination of both.
Diagnosis is performed through specialized blood tests, and treatment is pharmacological.
Certain infections (toxoplasmosis, rubella, etc.) have been associated with single miscarriages and essentially not with recurrent miscarriages (0.2%–0.5%).
At times, single or recurrent miscarriages have been linked to exposure to various harmful factors. In any case, pregnant women should avoid smoking, alcohol, and caffeine.
20%–30% of recurrent miscarriages remain unexplained and are treated empirically.
The prognosis for recurrent miscarriages is individualized and depends on the causes and the number of miscarriages. Overall, it is encouraging, considering that even after four consecutive miscarriages, the probability of a successful pregnancy is 60%–65%.
It is also worth noting that several causes of recurrent miscarriages — particularly those related to early miscarriage — may be associated with infertility and failed assisted reproduction attempts. In the context of investigating and treating infertility, histopathological examination of an endometrial biopsy, collected during diagnostic hysteroscopy, can play an important role.
Finally, it should be emphasized that both recurrent miscarriage cases and infertility cases involve multiple medical specialties, with one sole purpose, to help these truly burdened couples achieve a healthy baby!
In recurrent miscarriages due to chromosomal abnormalities, IVF with preimplantation genetic testing of the embryos may be recommended.
In the past, testing began after three consecutive miscarriages. The most recent guidelines of the European Society of Human Reproduction and Embryology (ESHRE) and the Royal College of Obstetricians and Gynaecologists (RCOG) define recurrent miscarriage as two or more pregnancy losses, which do not have to be consecutive. The reason is simple: couples should not have to go through a third loss to get answers.
The second major change concerns what we test for. Instead of a long list of tests “just to be sure,” the guidelines separate the tests that actually change treatment from those that only add cost and anxiety. A result with no treatment consequence does not help the couple.
Third, age matters too. The mother's age is the strongest known risk factor, because the share of eggs with chromosomal abnormalities rises over the years. That’s why in women over 35, testing should not be delayed.
Testing the male partner should not be skipped. His age, smoking and sperm DNA fragmentation may contribute, and the investigation is done together with an assessment for male infertility where needed.
Antiphospholipid syndrome is an autoimmune condition in which the body produces antibodies that promote blood clotting and affect how the placenta works. Diagnosis requires a combination of history and persistently positive tests, not a single isolated measurement.
Treatment is simple and evidence-based: low-dose aspirin from the time you start trying to conceive, and low molecular weight heparin injections from the moment the pregnancy is confirmed. With this treatment, the chances of a live birth improve significantly.
Women with antiphospholipid syndrome need close monitoring throughout pregnancy, because they have a higher risk of preeclampsia, fetal growth restriction and preterm birth. Treatment usually continues for about six weeks after delivery as well, to prevent blood clots.
Many “treatments” without evidence circulate for recurrent miscarriage. Knowing the difference protects the couple from unnecessary injections, cost and false hope.
After repeated losses, a positive test often brings more fear than joy. Organized monitoring from early on helps both medically and emotionally.
In studies, supportive care with frequent contact and access to the team was linked to better emotional well-being in women. Psychological support from a specialist is worth offering to both partners.
After a loss, almost every woman looks for what she did “wrong.” Most of the time, the answer is: nothing.
Removing the guilt is not just comfort. It is medical information that helps you focus on what actually changes the outcome.
Some lifestyle factors are linked to a higher risk of miscarriage and, unlike age, they can be changed.
These changes are not a “treatment” on their own. However, they add to the medical care and are within the couple's control.
Repeated pregnancy loss is grief, even if the pregnancy lasted only a few weeks. Studies show that a significant share of women have symptoms of anxiety, depression or post-traumatic stress in the months after a miscarriage. Partners are affected too, often silently.
Seek help from a mental health professional if:
There is no “right” time to try again. Medically, after an early miscarriage a long wait is usually not required, as long as the testing has been completed. Emotional readiness carries the same weight.
After two or more pregnancy losses. That is when testing of the couple begins.
Karyotype of both partners, testing for antiphospholipid syndrome, thyroid, blood sugar, assessment of the uterine cavity and, where possible, genetic analysis of the pregnancy tissue.
No. In about half of couples the tests are normal. Even then, the chance of a successful next pregnancy is high.
Even after three miscarriages, about six to seven out of ten women have a baby in the next pregnancy.
It may benefit women with previous miscarriages who have bleeding early in a new pregnancy. It is given only on medical advice.
No, ordinary everyday stress, mild or moderate exercise and sex have not been shown to cause miscarriage. Most early losses are due to chromosomal abnormalities in the embryo.
No. The combination of aspirin and heparin has a proven benefit in antiphospholipid syndrome. In unexplained miscarriages or inherited thrombophilia without a history of thrombosis, large studies did not show an improvement in births.
Yes. The man's karyotype is checked when indicated, while older age, smoking and high sperm DNA fragmentation have been associated with pregnancy loss.
Usually at around 6 to 7 weeks from your last period, when the embryo's cardiac activity can be seen. Earlier, the ultrasound often does not give a clear answer and increases anxiety.
