A structured, guideline-based workup for couples who have lost two or more pregnancies — what we test for, what we deliberately do not, and what the evidence actually supports.
Losing a pregnancy once is common. Losing one again is a different experience altogether — and the question that follows every couple into the consulting room is the same: is something wrong, and can it be found?
Often it can. Recurrent miscarriage has a defined set of causes, a defined set of tests that are worth doing, and a smaller set of treatments that genuinely change the outcome. This page sets out how the recurrent miscarriage clinic at Cosmic Women’s Hospital & IVF Center, Naroda, works through that. It is written to the current European (ESHRE) and American (ASRM) guidance rather than to local custom.
What counts as recurrent miscarriage
The definition has changed, and it matters, because it decides when a couple is entitled to a workup rather than being told to simply try again.
| Body | Definition used |
|---|---|
| ESHRE (European Society of Human Reproduction and Embryology) | Two or more pregnancy losses before 24 weeks. Includes losses confirmed only on a pregnancy test. Excludes ectopic and molar pregnancy, and failed implantation. |
| ASRM (American Society for Reproductive Medicine) | Two or more failed clinical pregnancies, confirmed on ultrasound or on histology. |
| Older UK practice | Three or more consecutive losses. Most guidance has now moved to investigating earlier. |
What we do at Cosmic: we begin the workup after two losses. We begin it after one loss if there is a clinical reason to — a loss after the first trimester, a known uterine abnormality, a previous stillbirth, a family history of clotting disorder, or maternal age above 35.
Why miscarriages happen
Most individual miscarriages are caused by a chromosomal error in the embryo. That is a random event, it is not inherited, and it is not caused by anything the mother did. What a recurrent miscarriage workup is looking for is the smaller group of causes that repeat.
| Cause | How often | How it is found |
|---|---|---|
| Chromosomal error in that particular embryo | The single commonest cause of any one miscarriage, and of roughly half of first-trimester losses | Genetic testing of the pregnancy tissue |
| Antiphospholipid syndrome (an autoimmune clotting condition) | Around 8–15% of women with recurrent loss | Blood tests, repeated after 12 weeks to confirm |
| A balanced chromosomal rearrangement in one partner | Around 2–5% of couples | Parental karyotype, in selected couples |
| Uterine factors — a septum, submucous fibroid, or intrauterine adhesions | A variable minority | Three-dimensional ultrasound; hysteroscopy where indicated |
| Thyroid disease, or diabetes that is not well controlled | Uncommon but important, because both are correctable | TSH, thyroid antibodies, HbA1c |
| Modifiable factors — weight, smoking, alcohol, heavy caffeine | Contributory | History |
| No cause identified | Around half of couples | — |
Frequencies are approximate and drawn from ESHRE and ASRM guidance; they vary between published series.
The tests we do
A recurrent miscarriage workup should be short, targeted and finished within one cycle. A long panel of tests is not a thorough workup — it is an expensive one. What we run:
- Antiphospholipid antibodies — lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein I. A positive result must be repeated at least 12 weeks later before it is called a syndrome, because these antibodies can appear transiently after an infection.
- Thyroid function and thyroid antibodies — TSH, and thyroid peroxidase antibodies.
- Assessment of the uterine cavity — three-dimensional pelvic ultrasound, with saline infusion sonography or hysteroscopy where the ultrasound raises a question.
- Genetic analysis of the pregnancy tissue, where a further loss occurs and tissue can be sent. This is the single most informative test available, because it separates “this embryo was chromosomally abnormal” from “something is wrong with the pregnancy environment”, and those two answers lead to completely different advice.
- Parental karyotype — offered selectively, based on the couple’s own history and family history, rather than run on everyone.
- Glucose control and vitamin D, where the history indicates.
The tests we do not do routinely — and why
Couples who have been through several miscarriages are often offered long investigation panels elsewhere. We do not run the following as routine, because the evidence does not support them and a normal or abnormal result does not change what we would advise:
- Inherited thrombophilia panels — Factor V Leiden, prothrombin gene mutation, protein C and S. Not recommended for recurrent first-trimester loss outside specific clinical indications.
- MTHFR gene testing. Guidelines specifically advise against it.
- Peripheral natural-killer-cell testing and broad immunological panels. Blood NK cells do not reliably reflect what is happening in the uterus, and testing them is recommended only in a research setting.
- Routine preimplantation genetic testing for aneuploidy (PGT-A) as a treatment for recurrent miscarriage in couples with normal karyotypes. It has not been shown to improve the chance of a live birth in this group.
- Empirical steroids, intravenous immunoglobulin (IVIG) or intralipid infusions. These are not recommended outside clinical trials. They are expensive, and they carry real side effects.
If any of these has been advised to you elsewhere, bring the report and the prescription to your consultation. We will go through the reasoning with you rather than simply repeating the test.
Treatments that are supported by evidence
Antiphospholipid syndrome
Where the diagnosis is confirmed on repeat testing, treatment is low-dose aspirin together with a prophylactic dose of low-molecular-weight heparin, started once the pregnancy test is positive and continued through the pregnancy. This is the clearest example in the whole field of a treatable cause that meaningfully changes the outcome.
Thyroid disease
Overt hypothyroidism is treated with levothyroxine and the dose is checked in early pregnancy. Where a woman is euthyroid but carries thyroid antibodies, randomised evidence has not shown that starting levothyroxine improves live birth rates, so we do not start it reflexively.
Progesterone
For a woman who has had a previous miscarriage and who bleeds in this pregnancy, vaginal micronised progesterone 400 mg twice daily, started when the bleeding begins and continued to 16 weeks, is supported by trial evidence — the benefit is concentrated in exactly this group, and is greater the more previous losses there have been. Progesterone given routinely to every woman with recurrent miscarriage, without bleeding, has not shown the same benefit.
Uterine abnormalities
Submucous fibroids distorting the cavity, and intrauterine adhesions, are corrected hysteroscopically. For a uterine septum the decision is made case by case: randomised evidence has not established a clear live-birth benefit from resection, so it is a discussion rather than an automatic operation.
Correctable general factors
Body weight, smoking, alcohol and glycaemic control all sit within the couple’s own control and all matter. This is the part of the plan that is easiest to skip past and worth not skipping.
Care in the next pregnancy
Whether or not a cause is found, close early-pregnancy support — early scanning, a named point of contact, and a written plan — is part of the treatment and not an add-on to it.
When no cause is found
For around half of couples, every test comes back normal. This is the hardest result to receive, and it is also, statistically, not the worst news.
In a large longitudinal study of couples with unexplained recurrent miscarriage, about three-quarters of couples went on to a live birth in a subsequent pregnancy without any specific treatment (Brigham et al., Human Reproduction, 1999). Age and the number of previous losses are the two variables that move that figure: the outlook is more favourable for younger women and for those with fewer previous losses. “Unexplained” means we have excluded the causes we can treat — it does not mean the outlook is poor.
Does recurrent miscarriage mean I need IVF?
Usually not. Recurrent miscarriage is a problem of the pregnancy continuing, not of conceiving, and most couples with recurrent loss conceive without difficulty. IVF is considered where there is a separate fertility problem alongside, or where a parental chromosomal rearrangement has been identified and preimplantation genetic testing for structural rearrangements is being discussed. That conversation, when it is needed, is led by Dr. Bhargavi Khatri, who leads the IVF programme here — you can read about the IVF unit in Naroda separately.
What to bring to the first consultation
- Dates of each pregnancy and each loss, and how many weeks each pregnancy had reached
- Any scan reports from those pregnancies
- Any histology or genetic report on pregnancy tissue, if tissue was ever sent
- All previous blood test reports, including any done elsewhere
- Details of any treatment already tried, with doses
- Your husband — the workup involves both partners, and the first consultation is best done together
Ultrasound and the PC&PNDT Act. Ultrasound in this clinic is used to assess the uterus, the ovaries and the progress of a pregnancy. Determination of the sex of the fetus is not done at this hospital and is prohibited by law under the Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994. Please do not ask our doctors or staff for it.
Common questions
I have had two miscarriages. Is it too early to be investigated?
No. Current ESHRE and ASRM guidance defines recurrent pregnancy loss as two or more losses, and we start the workup at that point.
Will the tests definitely tell us why?
In about half of couples a cause is identified. In the other half the tests come back normal, which is genuinely useful information — it rules out the causes that need treatment.
Did I do something to cause the miscarriage?
Almost certainly not. Ordinary activity, travel, work, exercise, intercourse and everyday stress do not cause miscarriage. The most common cause is a chromosomal error in the embryo that occurs at conception.
Should we wait before trying again?
There is no evidence that a long compulsory wait improves the outcome. The practical points are that the workup should be completed first, and that both partners should feel ready.
Can you tell us the sex of the baby on the scan?
No. Sex determination is not done at this hospital and is prohibited by law under the PC&PNDT Act, 1994.
Recurrent miscarriage clinic — Cosmic Women’s Hospital & IVF Center
3rd Floor, The Capital Corporate, Nr. Naroda Muktidham, Naroda, Ahmedabad – 382330
77-9383-9383
OPD 10:00 am – 8:00 pm · contact@cosmichospital.in
Written and reviewed by Dr. Rahul Khatri
MBBS, MS & DNB (Obstetrics & Gynaecology), FMAS
Consulting Obstetrician & Gynaecologist, Laparoscopic Surgeon
Director, Cosmic Women’s Hospital & IVF Center, Ahmedabad
Published 2 September 2026 · Next review due September 2027
This page is general information about a medical condition and is not a substitute for individual consultation. Investigation and treatment of recurrent miscarriage must be decided for each couple individually.
References
- ESHRE Guideline Group on RPL. Recurrent pregnancy loss: guideline of the European Society of Human Reproduction and Embryology — update 2022. Human Reproduction Open, 2023.
- Practice Committee of the American Society for Reproductive Medicine. Recurrent pregnancy loss: a committee opinion.
- Coomarasamy A, et al. A randomized trial of progesterone in women with bleeding in early pregnancy (PRISM). New England Journal of Medicine, 2019.
- Coomarasamy A, et al. Micronized vaginal progesterone to prevent miscarriage: a critical evaluation of randomized evidence. American Journal of Obstetrics & Gynecology, 2020.
- Brigham SA, Conlon C, Farquharson RG. A longitudinal study of pregnancy outcome following idiopathic recurrent miscarriage. Human Reproduction, 1999.
- Society of Obstetricians and Gynaecologists of Canada. Guideline No. 464: Recurrent Pregnancy Loss. JOGC, 2025.
Sign up for free Session!
It’s easy and free!
