Thursday, August 21, 2014

Recurrent Miscarriages: Is It A Hormonal Issue?


Dear Dr. Ramirez,

I am writing from Pennsylvania. In 2006, I had two or three miscarriages.  After that, I went to a fertility clinic and had TSH, prolactin, DRVV, and anti-cardiolipin antibodies tested.  All were normal.  I also had progesterone level checked at the very beginning of one of the pregnancies as well as a non-pregnant menstrual cycle after ovulation.  Both were normal.  I had irregular cycles that were anywhere from six to ten weeks apart.  I knew when I ovulated because I got pain in whichever ovary released the egg and always had a luteal phase of 14 days. I also conceived easily.  
The doctor felt the lining of my uterus was getting too old to sustain a pregnancy since so much time elapsed between cycles. In February 2007, I conceived on one round of Clomid and carried that child full-term.  I then had two more children in 2009 and 2011 with no help despite still having the same irregular cycles.  My cycles are a little better now and usually five to six weeks apart, but I have had three miscarriages again in September 2012, December 2013 and June 2014.  All the miscarriages I ever had were missed abortions with embryo development ending between week 5 and 6 with the exception of the most recent which ended at 11 weeks 5 days despite fetus having a strong heartbeat and normal looking development.  Since a drop in progesterone causes shedding of the lining of the uterus, is it safe to assume that since my miscarriages were not spontaneous that progesterone was not an issue?  Could other hormones be issues or was chromosomal defect the likely issue all these times? 

Thank you for your time. Sincerely, M. from Pennsylvania


Hello M. from the U.S. (Pennsylvania),

There are basically five known causes of recurrent miscarriages from the following abnormalities: genetic, anatomic, immunologic, hormonal and infectious.  When a woman has had two or three miscarriages, she automatically has earned the diagnosis of "recurrent pregnancy loss" and as such, needs to undergo a thorough evaluation of these elements.  The most common cause of miscarriages is genetic abnormalities and is responsible for 85% of miscarriages in women over 35 years old.  A recent study showed this cause to be less in younger women.  Genetic abnormalities can be caused from an inherited disorder or a spontaneous disorder, whereby the egg makes a genetic error when it is dividing leading to an abnormal embryo.  Most of these pregnancies will end before 12 weeks gestational age.

The recommended testing is as follows:

Genetic: wife and husband chromosomal analysis, saliva DNA analysis

Anatomic: diagnostic hysteroscopy, pelvic ultrasound, end cycle endometrial biopsy for dating and b-Integrin

Immunologic: Complete antiphospholipid antibodies, natural killer cells, Factor V Leiden, MTHFR, Antinuclear antibodies, Lupus anticoagulant, anti-Thyroid antibodies

Hormonal: FSH, LH, TSH, Prolactin, Estradiol, Mid-luteal Progesterone

Infectious: GC, Chlamydia, Ureaplasma/Mycoplasma, Toxoplasmosis

Age is probably the most common major cause which leads to an increase in genetic abnormalities.  Since you don't mention your age, that could be part of the problem if you are over 35 years old.  The good news is that most women with recurrent miscarriage will eventually have a successful pregnancy.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program



  1. Thank you Dr. Ramirez, It was a wonderful decision from your part to start a blog and share your views regarding IVF and it's treatments.

    1. Thank you. I have been blessed to follow this path and share my knowledge. I hope it is beneficial to all.

  2. Hello Dr Ramirez, Thank you for your beautiful work. Am 26years old suffering frm pcos for 8years. Got married two years ago and have been suffering from repeated chemical pregnancies.i hv had 5. The last was a month ago. 3 where from injectible cycles and two clomid all monitored. I av been on metformin for 4months consistently at a doze of 1700mg. Investigations done includes hsg prolactin,fsh, lh, progesterone on day 21 of a clomid cycle came bak to 30.8ng/ml. I have always had luteal suport with clomid. All efforts have been futile. Really confused as to what next to do. My doctor doesn't seem to consider chemical pregnancies as even "pregnancies". I would apprec your guidance through getting this solved. Please doctor.

    1. Chemical pregnancies are a form of miscarriage and so an evaluation for recurrent miscarriage/pregnancy loss needs to be done. Because the losses were early, the most likely causes are genetic or hormonal. Hormonal testing is the easiest to test and treat and is treated with supplemental progesterone and estrogen. Immunologic may also be an issue and is treated with heparin or lovenox, low dose aspirin, medrol Imethylprednisolone) and sometimes intralipids. Finally, genetic is the most common in older women and the only treatment option is repetition (until a good embryo is obtained) or genetic testing through IVF and PGS. It is important that you seek out someone that is proficient in recurrent pregnancy loss.

  3. Dr Ramirez. Thank you for the good work. I wanto ask if aspirin used in recurrent cp cud interfere with implantation? Is 75mg a too low doze than the 81mg in baby aspirin? What days of my cycle can I take estradiol to aid with thickening of the uterine lining. I suffer from pcos and have had 5 cp(chemical pregnancies). I would really apprec your help as I live in An environment where acess to fertility health care is not easy.

    1. The answer to your questions in order are as follows:
      1. No, aspirin does not interfere with implantation.
      2. 75 mg is adequate, but in the U.S. low dose aspirin is only available at 81 mg. I don't think anyone has looked at the two doses to see if there is a difference.
      3. Start from the beginning of the cycle.
      4. Answering your questions is the most I can do at this point unless you come to my clinic. I am also available to patients out of the are by email consultation subscription. Patients can sign up for a 1 year subscription costing $100 per month that allows to access me directly by email for unlimited questions. Since you don't have easily access, that is something you might want to consider. Of course, I can't treat you unless you physicallly come to my office, but I can make recommendations and give advice.



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