Recurrent Miscarriages Home > Services We Offer
Miscarriages are common and most women would have experienced at least one miscarriage. Women with recurrent pregnancy losses (3 or more losses) often need advice and further tests to ascertain the cause(s) for the miscarriages. A detailed history and examination including an ultrasound scan is essential in the evaluation of these women. Further blood tests may be necessary as well.

At FMGC, efforts are made to find the cause of miscarriages and advice is given to couples before they embark on their subsequent pregnancy. Experienced consultants offer close surveillance and support of their future pregnancies.
What is a miscarriage?
A miscarriage is the spontaneous loss of a baby before the 24th week of pregnancy. However, most miscarriages occur before 10-12 weeks of pregnancy. Miscarriages are very common. It is not unusual that many women miscarry more than once in their life.
How common is miscarriage?
Miscarriage occurs in about 10-20% of all pregnancies.

The risk of miscarriage, however, decreases as pregnancy advances. Miscarriage may be more common after a previous miscarriage, or less common following previously normal pregnancies. Recurrent miscarriage occurs when a woman has had more than two (3 or more) consecutive miscarriages in the past. This may prompt some tests to determine why this is happening.
Chances of subsequent miscarriage
First pregnancy 5%
Last pregnancy terminated 6%
Last pregnancy a live birth 5%
All pregnancies live births 4%
1 previous miscarriage 20%
2 previous miscarriage 28%
3 previous miscarriage 43%
Conditions which may contribute to early pregnancy loss:
  • Multiple pregnancy
  • Maternal age - the risk of miscarriage increases as maternal age increases. For women younger than 35, the miscarriage rate is 6.4%, for age 35-40, it is 14.7% and age of 40 years and older, it is 23.1%.
  • Poorly controlled diabetes mellitus
  • Fever over 38 degrees Celcius
  • Smoking - 30-50% increased risk
  • Occupational exposure to solvents increases the risk of miscarriage
When can we start trying again?
Some couples may wish to begin trying for a pregnancy right away, while others feel that they need time to get over this loss. There is no "right" or "wrong", and you have to discuss with your husband / partner and go with your feelings. If you have had a miscarriage, you should try and avoid pregnancy until you and your husband / partner are prepared to cope with the anxiety of another pregnancy and another loss.

There is no physical reason why you should not start trying soon. However, it is normally recommended that you wait for your first period after going home, and begin trying from then. There is some evidence that the risk of miscarriage is about 1.5 times increased if pregnancy occurs before a period is seen.
How can I improve my chances for the next time?
You can improve your chances of a successful pregnancy by being in the best of health. Having regular exercise, a healthy diet, reducing stress and getting your weight to within normal limits will help. Reduce your alcohol intake and stop smoking. Taking folic acid while trying to be pregnant until the 12th week of the pregnancy will help normal development of the baby's nervous system.
How will I feel after a miscarriage?
Many women and their husband/partner feel completely devastated after a miscarriage. Some describe a feeling that a part of them has "died". However, the reaction to a miscarriage can be variable. In addition to the grief, your body will be undergoing some major hormonal adjustments and this will make you feel very emotionally labile.

Couples normally go through the process of grief. Very often women feel as though they have failed. They may have a sense of guilt. Others react with anger and disbelief that it should happen to them. Yet others describe a feeling of numbness and emptiness following a miscarriage. Some couples withdraw, feeling alone and isolated, others may wish to talk about their loss.

Men often feel that they have to be strong for their wife. They may find their loss particularly difficult to talk about and may even deny that it has happened. Although it is difficult at first, it may help to try and tell family or close friends how you feel. These are all normal reactions to grief and bereavement. Components of the grieving process may be easier to accept and cope with if they are consciously understood.
The 4 stages of grief:
  1. Shock and numbness
  2. Yearning and searching
  3. Disorientation and disorganization
  4. Reorganization
Depression is very common after a miscarriage and strong emotions may cause a strain on relationships. Husbands/partners, family and friends must have patience and understanding. They should render their support and sometimes it helps to be open and talk about how you feel. Give yourself time to get over the loss. Some women find it extremely helpful to talk to someone else who has had similar experiences.

Support groups such as the "Pregnancy Loss Support Group" will be able to provide the appropriate emotional support after a pregnancy loss and also in subsequent pregnancies. They can also be a resource for information. Having a sympathetic doctor will provide you with the medical information and support you require. In particular, he/she will be able to reassure you and allay your anxieties and fears about future pregnancies. He/she will be able to address the medical questions you may have.
What if miscarriages recur?
A woman has recurrent miscarriages if she has had more than three or more consecutive miscarriages in the past. Recurring pregnancy loss affects about 1% of women. Many doctors may not investigate recurrent miscarriages until you have had 3 miscarriages. However, in certain situations, investigations are performed after two miscarriages as it does not make sense to wait for a third miscarriage. The cause recurrent miscarriages, however, cannot be found in about 50% of these women.
What investigations should be done if I have recurrent pregnancy losses?
An evaluation for known causes of recurrent pregnancy loss is usually initiated after 2 or 3 consecutive pregnancy losses. A medical history is taken first to assess previous losses in detail. Maternal health is assessed and information about her lifestyle and exposures to possible toxins is noted. An examination may reveal any stigmata of chronic illness and a pelvic examination may give the first impressions of congenital uterine abnormalities.
Further investigations may include:
  • Demonstration of a normally shaped uterine cavity (by either hysterosalpingogram or hysteroscopy). Recently, with the introduction of 3-D ultrasonography, the diagnosis of congenital abnormalities is much easier and readily available. 3-D ultrasound allows visualization of the uterus in special plane, the coronal or frontal plane and therefore making a diagnosis is possible compared with the conventional 2-D scan. These test may show other associated abnormalities such as intra-uterine adhesions and fibroids.
  • Establishing the diagnosis of cervical incompetence can be difficult. Generally, a suggestive history of late painless pregnancy loss is all that is used to diagnose the condition.
  • Chromosomal analysis of the couple (blood test) and the products of conception (miscarriage specimen)*
  • Laboratory testing for Anti-phospholipid syndrome (by blood test)
  • Ultrasound diagnosis of polycystic ovarian syndrome. When confirmed, blood is taken to check the hormone (luteinising hormone, LH and follicular stimulating hormone, FSH) levels. Fasting glucose, lipid profile and fasting insulin should be assessed as well.
*At least 50% of pregnancies that are lost in the first trimester have a major chromosomal abnormality when the products of conception are examined. About 30% in the second trimester and 5% in the third trimester are also found to have abnormal chromosomes. The doctor may therefore suggest that the products of conception from the ERPC / D&C be sent for chromosomal analysis but this can be quite costly.
Can recurrent miscarriages be treated?
Treatment of recurrent miscarriage is directed at the cause. However, as there is no definite cause in about half of the patients, there is much controversy regarding management of these unexplained cases. This has resulted in a number of empirical treatment options, most of which remain to be proven.

Even after three or more consecutive miscarriages, couples can still expect a 60-71 % chance that the next pregnancy would be successful. The probability of live birth appears to reduce by 23% for each additional miscarriage beyond three, in women with unexplained recurrent miscarriages. Successful pregnancy outcome is most likely in a woman with regular menstrual periods, fewer than four previous miscarriages, maternal age of less than 30 years, absence of antiphospholipid antibodies and a previous live birth.

1. Chromosome abnormalities

In patients with chromosomal problems, genetic counseling is important. A clinical geneticist should be consulted. Like in many countries, there are very few clinical geneticists in Malaysia. Therefore, you should consult your O&G specialist.

2. Congenital uterine abnormalities

Treatment of congenital uterine anomalies involves an operation. Your doctor will advise you on this.

3. Cervical incompetence (weakness)

Cervical cerclage is offered to women with a clear history of cervical incompetence or those at high risk of mid-trimester loss, such as those with a history of three or more pregnancies ending before 37 weeks gestation. This is done by putting a stitch (usually Mersilene tape) around the cervix at around 14 weeks, under general anaesthetic.

4. Polycystic ovarian syndrome (PCOS)

Women with PCOS having a high insulin level (due to insulin resistance) are given Metformin (an anti-diabetic drug). This will reduce the insulin resistance and correct the inherent problem. Some recent studies have also suggested that continuing Metformin into the first trimester of pregnancy will reduce the risk of miscarriage in these women. Other women with PCOS may be treated with ovulation-inducing drugs such as clomiphene and the injectables (for example GonaF and Puregon).

Surgical option for PCOS requires a laparoscopy and "ovarian drilling". This involves making small holes in the ovaries with a cautery needle or laser, However, the effects only lasts about one year.

5. Antiphospholipid syndrome

Women who have lupus coagulant or high anti-cardiololipin antibodies are treated with low dose aspirin and heparin injections daily.

6. Unexplained recurrent miscarriage

Various treatment options have been tried in this category of patients with no obvious cause for their recurrent pregnancy loss. These include:

(a) Tender Loving Care (TLC)

These women constantly worry about the outcome. They welcome reassurance, close monitoring, including serial ultrasonography to reassure them that the pregnancy is ongoing.

(b) Hormone treatment
  • Progestagens such as Duphaston. This drug, taken twice daily, has been shown to reduce the immunity of the woman so that her body does not reject the pregnancy. It can safely be taken before pregnancy or as soon as the pregnancy test is positive, right up to the end of the first trimester at 14 weeks.
HCG is the pregnancy hormone that increases exponentially during the early part of pregnancy, peaks at 8 to 9 weeks, levels off at 12 weeks and decreases after that. 5000 units of HCG is usually given twice weekly to support pregnancy in the first trimester.