Recurrent Pregnancy Loss Treatment

What Is Recurrent Miscarriage? Definition and Incidence

Recurrent miscarriage (Habitual Abortion) is generally defined, according to international definitions, as the loss of two or more consecutive pregnancies before the 20th week of gestation (although some older definitions require three or more losses, current approaches generally recommend starting an investigation after two losses). This condition affects approximately 1% to 5% of couples trying to conceive. Unlike sporadic (isolated) miscarriages, recurrent miscarriages are more likely to have a specific underlying cause, which is why a thorough investigation becomes important.

What Are the Possible Causes of Recurrent Miscarriage? The Comprehensive Investigation Process

Many different factors may underlie recurrent miscarriages. However, in approximately 50% of cases, no clear cause can be identified despite thorough investigation (unexplained recurrent miscarriage). Nevertheless, it is very important to conduct a comprehensive investigation to rule out or identify potential causes. The investigation process led by Prof. Dr. Nuray Bozkurt in Ankara generally includes the following steps:

1. Detailed Medical History and Evaluation:

• The couple’s age, general health status, and chronic illnesses.
• A detailed history of all previous pregnancies (the week at which each was lost, whether a curettage was required, whether the miscarriage tissue was examined).
• Family history of recurrent miscarriage, genetic disease, or clotting disorders.
• Menstrual pattern, gynecological history (infections, surgeries).
• Lifestyle factors (smoking, alcohol, nutrition, occupational exposures).

2. Investigation of Genetic Factors:

• Parental Karyotype Analysis: Blood samples taken from the mother and father are examined for the structure and number of chromosomes. In approximately 2-5% of couples, structural chromosomal abnormalities (e.g., balanced translocation, inversion) can be identified that do not cause a health problem in the parents themselves but may lead to imbalances in the products of conception.
• Genetic Examination of the Miscarriage Tissue (POC Testing): If possible, genetically examining the pregnancy tissue (placenta, embryonic tissue) obtained from the most recent miscarriage can provide highly valuable information in determining whether the cause of the miscarriage was a random chromosomal error in the embryo (aneuploidy) or a structural problem inherited from the parents.

3. Evaluation of Anatomic (Uterine Structure) Factors: Abnormalities in the structure of the uterus can prevent the embryo from implanting or developing healthily.

• Imaging Methods:
  
  • Transvaginal Ultrasonography (especially 3-Dimensional – 3D Ultrasound): Provides a detailed view of the uterine structure.
  • Saline Infusion Sonohysterography (SIS): Sterile fluid is instilled into the uterus to allow clearer ultrasound visualization of the uterine cavity; it is effective at detecting problems such as polyps, fibroids, and adhesions.
  • Hysterosalpingography (HSG – Uterine X-ray): Shows the shape of the uterine cavity and the patency of the fallopian tubes.
  • Hysteroscopy: Direct visualization of the inside of the uterus with a thin camera. It offers both diagnostic and, in the same session, therapeutic options (cutting a septum, releasing adhesions, removing a fibroid/polyp).
• Problems Investigated: Uterine septum, intrauterine adhesions (Asherman syndrome), fibroids growing into the uterine cavity (submucous myoma), endometrial polyps, congenital uterine anomalies (double uterus, etc.), cervical insufficiency (usually suspected based on history and examination).

4. Investigation of Endocrine (Hormonal) Factors: Hormonal imbalances can affect the continuation of pregnancy.

• Thyroid Function Tests: TSH, Free T4, and Anti-TPO antibodies are measured to investigate for subclinical hypothyroidism or autoimmune thyroid disease (Hashimoto’s).
• Diabetes Screening: Fasting blood glucose and/or HbA1c are measured to investigate for uncontrolled diabetes or a predisposition to diabetes.
• Prolactin Level: The blood prolactin hormone level is measured (hyperprolactinemia).
• Other Hormones: Although the diagnosis of luteal phase deficiency (progesterone deficiency) is controversial, in some cases progesterone levels or other hormones (FSH, LH, Estradiol) may be evaluated.

5. Investigation of Immunological Factors: An abnormal immune response to pregnancy can cause miscarriage.

• Antiphospholipid Syndrome (APS) Testing: This is the most important and treatable immunological cause of recurrent miscarriage. Blood levels of Lupus Anticoagulant, Anticardiolipin Antibodies (IgG and IgM), and Anti-Beta-2-Glycoprotein I Antibodies (IgG and IgM) are checked. This syndrome disrupts placental function by creating a tendency toward clotting in the blood vessels.
• Other Immunological Tests: Tests such as Natural Killer (NK) cells, cytokines, and HLA matching are generally investigational and are not routinely recommended.

6. Investigation of Thrombophilia (Blood Clotting Tendency) Factors: Besides APS, inherited clotting disorders may also be investigated.

• Inherited Thrombophilia Panel: Tests such as Factor V Leiden mutation, Prothrombin gene (G20210A) mutation, Protein C, Protein S, and Antithrombin III deficiency. Their relationship with recurrent miscarriage outside of APS is not clear, and routine screening for them is debated; they are generally requested in selected cases or when there is a family history.

7. Investigation of Infectious Factors:

• Chronic Endometritis: If chronic inflammation of the uterine lining is suspected, an endometrial biopsy can be taken during hysteroscopy for pathological and microbiological examination.
• Other Infections: The role of systemic infections (TORCH, etc.) is more relevant to sporadic miscarriages; they are not routinely screened for in recurrent miscarriage.

8. Evaluation of the Male Factor:

• Standard semen analysis is generally normal. However, in some cases, particularly in unexplained recurrent miscarriage, advanced tests such as the Sperm DNA Fragmentation Index, which shows sperm DNA damage, may be considered.

9. Lifestyle Factors: Detailed questioning identifies habits that may pose a risk.

Recurrent Miscarriage Treatment: Cause-Directed and Supportive Approaches

Treatment for recurrent miscarriage is planned according to the specific cause identified through investigation. If no clear cause is found (in around 50% of cases), couples are offered supportive care, lifestyle adjustments, and close follow-up. In Ankara, Prof. Dr. Nuray Bozkurt will evaluate your particular situation and create the most appropriate treatment or management plan for you.

• Approaches for Genetic Causes:
  
  • Genetic Counseling: If a chromosomal problem is found in the parents, detailed information is provided about what this means, the risks in future pregnancies, and reproductive options (natural conception and its risks, IVF with PGT, sperm/egg donation, adoption).
  • Preimplantation Genetic Testing (PGT-SR): In couples carrying a structural chromosomal abnormality (e.g., balanced translocation), embryos obtained through IVF are genetically examined before being transferred to the uterus, so that only healthy embryos are transferred.
• Treatments for Anatomic Causes:
  
  • Hysteroscopic Surgery: Procedures such as cutting and correcting a uterine septum (metroplasty), releasing intrauterine adhesions (synechiae), and removing submucous fibroids or polyps are generally performed successfully via hysteroscopy (a closed/minimally invasive method).
  • Cervical Cerclage: In cases diagnosed with or suspected of cervical insufficiency, this procedure involves placing a supportive stitch in the cervix, usually at 12-14 weeks of pregnancy.
• Treatments for Endocrine Causes:
  
  • Thyroid Treatment: In cases of hypothyroidism or subclinical hypothyroidism, L-thyroxine hormone is given to bring the TSH level into the target range for pregnancy, and it is monitored throughout pregnancy. If autoimmune thyroiditis is present, close follow-up is carried out.
  • Diabetes Management: Blood sugar levels are kept under tight control before and during pregnancy through diet, exercise, and, if necessary, medication or insulin.
  • Prolactin Treatment: Elevated prolactin levels are normalized with medication.
  • Progesterone Support: Particularly in unexplained recurrent miscarriage or proven luteal phase deficiency, progesterone hormone supplementation (vaginal, oral, or injectable) may be tried in early pregnancy (usually up to the first 10-12 weeks). Although its effectiveness is debated, some guidelines recommend it.
• Treatment for Immunological Causes (Antiphospholipid Syndrome – APS):
  
  • Low-Dose Aspirin and Heparin: In patients with a confirmed diagnosis of APS, low-dose aspirin (usually 81-100 mg) started as soon as pregnancy is detected, together with daily subcutaneous heparin (low molecular weight heparin – LMWH) injections, is the standard treatment and significantly improves pregnancy success. Treatment generally continues throughout pregnancy and sometimes into the postpartum period.
• Approaches for Unexplained Recurrent Miscarriage:
  
  • Supportive Care (Tender Loving Care – TLC): This is one of the most important approaches. The close attention, empathy, reassurance from frequent check-ups, and psychological support the doctor provides the patient can, on its own, improve the success rate.
  • Lifestyle Optimization: Factors such as achieving or maintaining a healthy weight, completely quitting smoking and alcohol, balanced nutrition, and avoiding stress are important.
  • Empirical (Not Evidence-Based/Experimental) Treatments: Treatments such as low-dose aspirin, progesterone, IVIG (intravenous immunoglobulin), intralipid infusions, and corticosteroids are sometimes tried, but their effectiveness has not been clearly proven scientifically and they are not routinely recommended. Such treatments may only be considered in very select cases and after detailed discussion with the patient.

Chances of Success After Recurrent Miscarriage and the Importance of Psychological Support

A history of recurrent pregnancy loss creates enormous psychological pressure on couples. However, it is important not to lose hope. As a result of investigation and treatment:

• When a specific underlying cause is found and treated (for example, APS, a uterine septum, thyroid disease), the live birth rate in the subsequent pregnancy increases markedly.
• Even in couples with unexplained recurrent miscarriage, without any specific treatment being applied, the likelihood of a live birth in a subsequent pregnancy is generally high (approximately 60-75%). Close follow-up and supportive care play an important role in this success.

Getting professional psychological support to cope with the grief, anxiety, depression, and guilt experienced during this process is very important. Couples therapy, individual therapy, or support groups for couples experiencing recurrent miscarriage can be of great benefit on this difficult journey.

Prof. Dr. Nuray Bozkurt’s Expertise in the Investigation and Treatment of Recurrent Miscarriage in Ankara

Recurrent pregnancy loss is a complex condition that requires a multidisciplinary approach and specialized expertise. At her clinic in Ankara, Prof. Dr. Nuray Bozkurt can support you in this area as follows:

• Comprehensive Evaluation: She is experienced in taking a detailed history, performing examinations, and planning and interpreting the advanced tests (genetic, hormonal, immunological, anatomic) required to investigate all possible causes of recurrent miscarriage. She coordinates with reliable laboratories and centers in Ankara for the necessary tests.
• Personalized Treatment: She creates evidence-based treatment and management plans tailored to you, whether directed at an identified cause or for unexplained cases.
• Necessary Interventions: She is qualified to perform surgical procedures such as hysteroscopy to correct intrauterine problems (septum, adhesions, fibroids), or to refer you to centers experienced in this field. She prescribes and monitors medical treatments (progesterone, aspirin/heparin, etc.) when clinically indicated.
• A Patient and Supportive Approach: Aware of how challenging this process is, she maintains a patient, understanding, and empathetic attitude toward you and your partner. She answers all your questions, listens to your concerns, and offers realistic expectations while giving you hope.
• Close Follow-up and Accessibility: She offers close follow-up and easy access to communication throughout treatment and in your subsequent pregnancies (0538 983 18 78) (0312 284 00 12).

If you are experiencing recurrent pregnancy loss and would like to investigate the causes and create a treatment plan tailored to you, do not lose hope. You can make an appointment at our clinic in Ankara by calling 0538 983 18 78 to meet with Prof. Dr. Nuray Bozkurt and learn how we can help you through this difficult process. With a comprehensive evaluation and a supportive approach, we are with you on the path to a healthy pregnancy.