How many miscarriages are too many?

Miscarriage is a devastating experience for a woman. When a woman conceives, she builds a dream around her pregnancy and starts planning the future along with the baby that is coming. A sudden loss of the pregnancy shatters her dreams and affects her, not only physically, mentally, emotionally, but also socially. If losing one pregnancy is so traumatic to a woman, one can imagine what will happen if this problem occurs the second time and then keeps on recurring. It can really destroy the woman and affect the entire family.

So, how many miscarriages are too many? I would say, even one miscarriage is very bad for a woman. However, if one sees medically, when there are two or more miscarriages, it is termed as Recurrent Miscarriages and the couple is investigated for the underlying cause. Usually after first miscarriage the couple is counselled about the pregnancy loss. The cause in that case can be a genetically abnormal pregnancy, due to the process of mutation, at the time of conception itself. Doctors usually do not recommend different tests to find out the cause. The couple is asked to report when the wife is pregnant the next time.

Now, it is a debatable issue, whether a couple should be investigated after one miscarriage or after two or more miscarriages. The chance of having a miscarriage in the next pregnancy after one miscarriage is 11-14%. Hence, the couple is routinely not investigated for the cause of a miscarriage. There are many investigations and they are very expensive. However, for a couple who has already lost a pregnancy, to lose one more means further trauma. These couples very often ask the doctor, “Do you want us to lose one more baby to find out the cause?”

This is always a dilemma for a doctor. It is my personal opinion that every couple has a right to know about the problem that caused the miscarriage. Making the couple face the trauma again is not justified on a humanitarian ground, though the medical science feels the other way. Why does Medicine says that we should wait till second miscarriage?. Is it because the chance of miscarriage in the subsequent pregnancy is 11-14% after previous one miscarriage? Actually, the data says that the chance of a miscarriage after two miscarriages is 18%, not much different from that after one miscarriage. Maybe, is it to avoid the patient spending a lot of money on the investigations? Or the reason is that the insurance companies don’t want to pay for these tests (as happens in developed countries).

Whatever maybe the underlying reason, with every pregnancy loss, the woman loses her morale, gets depressed. Hence, every couple has the right to know the cause for a miscarriage so that it can be prevented in the subsequent pregnancy – be it after one miscarriage or more. In our opinion, a couple should be investigated for the underlying cause, even after the first miscarriage.

Having said all this, if we see the guidelines of various Gynaecological & Obstetric societies across the world, investigation are recommended after 2 or 3 miscarriages to find out the underlying cause (American society, ASRM, guidelines say 2 miscarriages and European society, ESHRE, guidelines say 3 miscarriages). However, the sad part is, in 50-60% of such couples with Repeated pregnancy loss, the underlying cause cannot be pinpointed and it is labelled as unexplained and left to nature. In such so called “Unexplained” pregnancy losses, the underlying cause can be immunological rejection of pregnancy, which is antigenically 50% different from the mother (known as “Semi-allograft”).

More about “Unexplained Pregnancy Loss” in the next blog.

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