Recurrent Pregnancy Loss Management at Yaal Fertility Centre, Chennai

Nearly every woman who miscarries searches her memory for the thing she did wrong. The heavy bag. The late night. The glass of wine before she knew. The stressful week at work. The exercise class. The argument.

None of these cause miscarriage. Normal activity, normal work, normal exercise, normal stress, and normal sex do not end pregnancies. This is not reassurance offered to be kind — it is what the evidence shows, and it needs saying because the guilt is so widespread and so unearned.

In roughly 50–60% of early miscarriages, the cause is a chromosomal abnormality in the embryo. When an egg and sperm combine, the resulting embryo occasionally receives the wrong number of chromosomes. Such an embryo cannot develop, and the pregnancy ends. This happens at the moment of conception, before you knew you were pregnant, and there is no behaviour — before, during, or after — that could have altered it. The likelihood of it happening rises with age, because egg quality declines with age. It is nobody’s failing.

The reason we say this first, before any discussion of tests and treatments, is that the guilt is itself harmful. It compounds grief, it makes women hide their losses, and it delays them from seeking the investigation they are entitled to.

You are permitted to grieve a pregnancy that other people never knew about. And you are permitted to ask for answers.

The purpose of investigation is to find whether something identifiable and treatable lies behind the losses. Several categories of cause are looked for.

Chromosomal and genetic causes. The most common single explanation for early loss is a chromosomal error in the embryo itself, occurring at conception. Separately, one parent may carry a balanced chromosomal rearrangement — a translocation — in which their own chromosomes are complete but rearranged. Such a carrier is healthy, but a proportion of the embryos they produce inherit an unbalanced amount of genetic material and miscarry. This is why parental karyotyping forms part of the workup.

Uterine and structural causes. A uterine septum, fibroids, polyps, adhesions, or a congenital abnormality of the uterus can interfere with implantation or with the developing pregnancy. Many of these are surgically correctable, which is why the uterus is assessed with hysteroscopy or 3D ultrasound.

Hormonal causes. Thyroid disorders, poorly controlled diabetes, and progesterone deficiency can all contribute, and all are treatable.

Antiphospholipid syndrome and clotting disorders. Antiphospholipid syndrome is an autoimmune condition that promotes clotting and is one of the most important treatable causes of recurrent loss — which is precisely why it is tested for. Inherited thrombophilias are also assessed.

Immunological factors, in which the immune response to the pregnancy is implicated, are also investigated.

And then the finding that many couples find hardest of all: in roughly 50% of cases, no cause is identified. This is deeply frustrating, and it can feel like being dismissed. It is not the same thing as being told nothing is wrong or that nothing can be done — as the next section explains.

Around half of couples complete a full investigation and are told that everything came back normal. This is often experienced as the worst possible outcome: no answer, no explanation, and the sense that the losses will simply continue.

It is worth reframing what that result actually means. Every treatable cause has been looked for and excluded. Your uterus is normal. Your hormones are normal. You do not have antiphospholipid syndrome. Neither of you carries a chromosomal rearrangement. That is genuinely good news, even though it does not feel like it, because the alternative results would each have described a problem.

And the outlook in unexplained RPL is far better than most couples fear. With supportive care, the chance of a successful next pregnancy is in the region of 70–80%. Read that again if you need to. Unexplained recurrent loss is not a diagnosis of infertility, and it is not a prediction that it will happen again.

What supportive care means in practice is close monitoring through early pregnancy — regular ultrasound scans, hormone level checks, progesterone support where indicated, and rapid access to the team when you are worried. Some of this is clinical and some of it is simply not being left alone during the weeks you most dread. Both matter.

What we will not do is offer you unproven and expensive treatments simply because the honest answer is uncomfortable. Recurrent pregnancy loss attracts a great many interventions with weak evidence behind them, and vulnerable couples are frequently sold them. Dr. Rukkayal will tell you what the evidence supports.

A proper RPL workup is broad, because the possible causes are varied and there is no single test that covers them. Investigation is generally offered after two or more consecutive losses.

• Parental karyotyping — blood tests on both partners to look for a balanced chromosomal rearrangement.
• Genetic analysis of the pregnancy tissue (products of conception), where this can be obtained. This is one of the most informative tests available, because it can show directly whether the loss was chromosomal — and therefore random and unlikely to recur — or not. It is worth asking about at the time of a loss, when it is still possible to collect.
• Uterine assessment — hysteroscopy or 3D ultrasound to look for a septum, fibroids, polyps, or adhesions.
• Hormonal evaluation — thyroid function, blood sugar, and progesterone.
• Antiphospholipid antibodies and thrombophilia screening — testing for the clotting disorders that are among the most treatable causes.
• Immunological screening.

Where a cause is found, treatment follows it directly: surgical correction of a uterine abnormality, thyroid or diabetic control, progesterone support, anticoagulation in antiphospholipid syndrome, or IVF with PGT where a chromosomal rearrangement is carried — PGT allows embryos to be screened before transfer so that only those with a normal or balanced chromosome complement are used.

The tests are not trivial in number, and going through them after a loss is emotionally hard. But an untested couple is left guessing, and treatable causes such as antiphospholipid syndrome or a uterine septum go undetected — which is the worst outcome of all, because those are the ones that can be fixed.