Recurrent miscarriages are among the most dramatic problems in gynecology. Besides the medical aspect of the event, there is also a moral and psychological aspect, which significantly affects the couple, especially the woman. In fact, women can become fearful of even getting pregnant due to the fear of having another miscarriage.
When we refer to recurrent miscarriage, we mean at least two miscarriages. Miscarriage usually occurs in the early period, pointing to the first 3 months of pregnancy. If this occurs before the gestational sac is even seen, it is called a chemical pregnancy. In fact, we describe all pregnancy losses before the 20th week as miscarriages. However, in miscarriages that occur after the 12th week, the mother’s cervical insufficiency can be considered as the cause, or uterine anomalies may play a role.
When evaluating a couple with recurrent miscarriages, the mother’s age, consanguineous marriage, the mother’s ovarian capacity, and the weeks of pregnancy loss, as well as whether they have children born previously, should be taken into consideration. Following the woman’s examination, the woman’s uterine film and hormone tests, tests for coagulation, and blood tests to check for diabetes, thyroid, and rheumatological diseases should be investigated. Genetic tests should be requested from both the woman and the man, and if there is a problem with the chromosomes, it should be identified.
It is important to evaluate the uterine film well. It should be assessed whether there is a pathology that disrupts the uterine cavity, such as a septum, polyp, or myoma in the internal structure of the uterus. Furthermore, the presence of uterine malformation, especially a T-shaped uterus, is important. Whether there is any fluid accumulation in the tubes or any pathology in the tubes should be evaluated with a uterine film. Partial blockages in the tubes or fluid accumulation we call hydrosalpinx can also cause the deterioration of pregnancies. When such suspicions exist, we can see and simultaneously treat these pathologies, if present, with an endoscopic procedure called hysteroscopy to evaluate the inside of the uterus. Again, there may be adhesions within the uterus after curettages performed due to previous miscarriages, and in this case, the inability to conceive or, if pregnancy occurs, termination with a miscarriage may develop. The treatment of intrauterine adhesions is also performed with hysteroscopy; occasionally, if there are very dense adhesions, it may be necessary to perform hysteroscopy more than once. If a pathology has been detected in the tubes, such as hydrosalpinx, evaluation with laparoscopy, an endoscopic procedure performed by entering through the navel with a camera, is recommended; in the same session, if a pathology exists, the adhesion in the tube can be opened or, if the damage to the tube is extensive, the tube can be removed.
Occasionally, hormonal problems in the woman can cause recurrent miscarriages. The woman being overweight predisposes her to miscarriages. Thyroid disorders, unnoticed diabetes, and polycystic ovary syndrome can cause recurrent miscarriages, and it is possible to have a healthy pregnancy after the treatment is regulated. Again, the woman may have unnoticed rheumatological or coagulation system-related diseases. With such evaluations, a disease that the patient was unaware of until then can be revealed. Therefore, a detailed evaluation before a new pregnancy can both reveal a possible disease and ensure that the new pregnancy reaches its term healthily.
Some tests can also be performed for men in recurrent miscarriages. DNA damage tests are one of them. Quitting smoking is strongly recommended, especially for men who smoke. A balanced diet and losing excess weight, if present, can be beneficial.
In the genetic tests of the expectant parents, genetic defects can sometimes be detected. Recurrent pregnancy losses can occur in genetic defects called translocations. In this case, a healthy pregnancy will be achieved by applying IVF treatment, and after the resulting embryos are examined genetically, selecting and transferring the normal embryo into the uterus.
In summary, it is essential to evaluate a couple with recurrent miscarriages in detail. The woman’s examination, uterine film, and blood tests should be performed. Sperm analysis in the male should be conducted in a good laboratory. Although it is generally a psychologically very challenging problem, 40-60% of these couples can achieve a healthy pregnancy. It is beneficial to support the couple psychologically, especially the woman, and to provide positive suggestions. However, a new pregnancy should not be allowed without a detailed evaluation and investigating possible causes. Every pregnancy loss and a subsequent curettage carries the risk of damaging the endometrium, which is the inner lining of the uterus.
