Pregnancy after a miscarriage can be anxiety inducing and confusing, to say the least. It’s natural to have many conflicting emotions and a lot of questions during this time.
By OBGYN Dr. Mare Mbaye
Pregnancy after a miscarriage can be anxiety inducing and confusing, to say the least. Losing your baby at any stage can be devastating and the fear of it happening again can make the decision to try for another pregnancy more difficult. It’s natural to have many conflicting emotions and a lot of questions during this time: When can I start trying again? What are the chances of another miscarriage? When should I see a fertility specialist?
Read on to get answers to these questions and more.
First and foremost, what is a miscarriage? A miscarriage is the spontaneous loss of a pregnancy before reaching the 20th week. Early pregnancy loss falls within this category as well since it is the loss of a pregnancy within the first trimester (before the 14th week).
There are different types of miscarriages.
- Missed: miscarriage where there were no signs or symptoms. This is typically diagnosed when a patient presents for a routine prenatal visit, and the baby no longer has a heartbeat on ultrasound.
- Spontaneous: miscarriage as most people think of it, with obvious signs and symptoms like bleeding and cramping. These can be further divided into incomplete and complete miscarriages. Incomplete refers to a miscarriage where the uterus still retains some of the pregnancy. Complete refers to a miscarriage where the entire pregnancy has passed from the uterus.
The most common signs and symptoms of a miscarriage are vaginal bleeding with or without abdominal pain. In the case of missed miscarriages, these symptoms don’t typically happen, though in some cases patients may have mild cramping or spotting.
Clinically recognized miscarriages occur in up to 25% of pregnant people, which makes them much more common than people realize. An abnormality with the baby's chromosomes is responsible for about 60% of miscarriages. Most of these chromosome issues happen by chance as the embryo divides and grows and are not preventable. However, we do know that older reproductive age and certain genetic problems can increase this risk.
Recurrent pregnancy loss (RPL) is diagnosed when a patient has had two or more miscarriages. After three repeated miscarriages, most providers will recommend a thorough exam and a workup. Less than 5% of pregnant people experience two miscarriages, and only about 1% will experience three.
The predicted risk of miscarriage in a future pregnancy remains around 20% percent after one miscarriage. After two consecutive miscarriages, the risk increases to about 28% and after three or more consecutive miscarriages, the risk rises to 43%. In addition to the genetic reasons listed above, problems with reproductive organs and certain medical conditions can increase the risk of RPL and are therefore part of the workup.
Many times though, the cause of miscarriage isn't known. In fact, in up to 75% of people who experience recurrent miscarriages, a cause is never identified. However, depending on certain factors such as age and number of previous pregnancies, the chance for a future successful pregnancy can be over 60%.
Getting pregnant after a miscarriage
Miscarriage is usually a one-time occurrence, and most people go on to have healthy pregnancies later on. You can get a period within four weeks after a miscarriage and ovulate and become pregnant as soon as two weeks after a miscarriage. Therefore, one of the most common questions is when to start trying to conceive again after a loss.
The recommendation used to be for couples to wait a number of months before trying to get pregnant again after a miscarriage, a later pregnancy loss, or a stillbirth. We’ve now learned that the uterus is remarkably resilient and recovers quickly after a miscarriage, so in most cases, it’s okay to try again as soon as you're ready and your doctor has cleared you-–as a general rule, sex is not recommended for two weeks after a miscarriage due to the risk of an infection.
The only exception to this is if there are any medical conditions to be managed prior to another pregnancy. For example, patients with polyps or fibroids (non-cancerous growths of the uterus) sometimes need to have these removed to increase their chances of pregnancy. In other cases, such as with retained pregnancy products, which is common with missed miscarriages, your provider may recommend you take medication or undergo a procedure to remove the pregnancy from the uterus. This procedure is called a dilation and curettage (D&C) when done prior to the 14th week of pregnancy or a dilation and evacuation (D&E) when performed after the 14th week. Make sure to check with them about your specific situation.
In addition to physical considerations, the emotional recovery from a miscarriage can take some time. Not every woman feels okay about trying again as soon as her body is ready. Intense feelings of loss are normal regardless of the stage of pregnancy at which the loss occurred. You and your partner might experience sadness, anxiety, anger, or guilt. Don't rush this grieving process; it is important to process your emotions in whatever way works for you.
Other pregnancy losses and TTC
- Pregnancy loss can also occur in other settings besides miscarriages. An ectopic pregnancy is when an embryo (the fertilized egg) implants and grows outside the uterus. Over 90% of ectopics occur in the fallopian tubes. As they grow, these pregnancies can cause the tube to burst which can lead to major internal bleeding–as a result, ectopic pregnancies are considered an emergency. The recovery from an ectopic pregnancy is very similar to a miscarriage. Depending on how it is managed (with medication or surgery), this can vary so it’s important to discuss with your provider when they recommend starting to TTC again. Read more about ectopic pregnancy.
- A molar pregnancy is an abnormal pregnancy that requires surgery to fully remove it and close follow up with labs. This type of pregnancy is considered precancerous because without proper resolution there is a chance these cells can invade into the uterus or spread to other parts of the body. With molar pregnancies, the recommendation to avoid pregnancy until after blood work has shown complete resolution for a specified amount of time. This significantly decreases the risk of the abnormal pregnancy cells turning cancerous. Read more about molar pregnancy.
- Stillbirth is defined as the death of a fetus in the uterus after 20 weeks of pregnancy. For stillbirths, the recovery period is typically longer than for miscarriages and ectopics. Because they occur later in pregnancy, people tend to need more time both from a physical and emotional standpoint. Read more about stillbirth.
How to increase your chances of getting and staying pregnant
Pregnancy loss is made that much harder by the fact that there’s often nothing that can be done to prevent it. However, making healthy lifestyle choices is important for future pregnancies.
First, you should make sure that you’ve discussed when to TTC again with your provider in case they want you to wait for any reason. Once you are back to having regular periods (usually four to six weeks after a miscarriage), you should start to track them again so that you can time intercourse around your fertile period. Many people find that tracking ovulation with ovulation prediction kits is helpful. If your periods do not return or are irregular, let your provider know.
Taking a daily prenatal vitamin or folic acid supplement is still very important, and often, providers recommend continuing them even if you are not planning to TTC again for a few months. There is no specific diet or exercise plan that is better than any other. The most important thing you can do is focus on a healthy diet and exercise plan that is sustainable and works for you. If you have specific questions, talking to your provider or to a nutritionist who specializes in fertility and preconception may be helpful.
During pregnancy, make sure to limit caffeine and avoid drinking alcohol, smoking, and using illicit drugs. If you are 35 years or older and have not had a pregnancy after six months or if you are under 35 and have not had a pregnancy in 12 months, you should see your OBGYN or an REI (fertility) specialist.
Miscarriages and other forms of pregnancy loss can be devastating, especially when the cause is unknown. It’s important to allow yourself proper recovery from both a physical and emotional standpoint. While miscarriages are generally one-off occurrences, they provide an opportunity to treat any underlying causes or improve lifestyle risk factors that may have contributed to the loss. Taking those steps can improve your chances for a healthy pregnancy and baby in the future.