What to do after recurrent miscarriage – the tests and treatments to ask about

Recurrent miscarriage treatment, testing and paths forward

This is a question we hear often from our TRB community: after more than one miscarriage, where do you turn, and why is it so hard to find answers? It’s a deeply difficult experience — one that many of us share, yet so few talk about openly.

So, this National Infertility Awareness Week 2025, we wanted to bring this conversation into the spotlight.

Eloise Edington sat down with Dr. Nischelle Kalakota, Reproductive Endocrinologist at Aspire Houston Fertility Institute (a Prelude Network clinic), to talk honestly about recurrent miscarriage, how to find answers, and what can actually make a difference.

Watch as we cover:

• What counts as recurrent miscarriage & when to seek help.

• The most common (and often missed) causes.

• Key tests that can provide clarity and direction.

• How IVF with PGT-A may help reduce risk.

• The role of lifestyle and emotional support.

• What to do when testing is inconclusive.

• How to advocate for the care you deserve.

Whether you’re at the beginning of your journey or searching for a new path forward, we see you.

Transcript

Eloise Edington 

Hi everyone, welcome. Today I have the pleasure of speaking with Dr. Nischelle Kalakota, who is a reproductive endocrinologist and infertility specialist at Aspire Fertility Houston, part of the Prelude Network.

This is perfectly timed as it’s currently National Infertility Awareness Week. We are going to be discussing what to do after recurrent miscarriages — the tests and treatment options to know about. So, welcome.

Hi to those who are joining. I’m wearing orange today for National Infertility Awareness Week, and we’re looking forward to this conversation today. Ready, and we can go through them as we’re chatting.

Hello everyone, nice to see you today. Welcome. 

Dr. Nischelle Kalakota

Thank you so much for having me. 

Eloise Edington 

It’s lovely to see you today. I gave you a brief introduction. As you can see, I’m wearing orange because of National Infertility Awareness Week, so it is a timely conversation to be discussing and supporting people, answering questions around recurrent miscarriage, tests, treatment options to know.

If you could please introduce yourself — a little bit more about Aspire Fertility Houston — and then we can get started with some great questions we have for everyone today.

Dr. Nischelle Kalakota

Wonderful. Thank you so much. Well, my name, as you said, is Dr. Nischelle Kalakota. I am a board-certified OB-GYN as well as a fellowship-trained specialist in reproductive endocrinology and infertility.

I am a part of the Houston Aspire Network. We’re one of the largest fertility practices in Houston. We have over 13 physicians and we see thousands of women a year, helping them on their fertility journey and building their families.

Eloise Edington 

Fantastic. Thank you for that introduction. And if anyone has a question as we go along, please don’t hesitate to ask — even if you want to private message, that’s fine.

So, if you want to tell us a little bit about your specialty, your background, anything else to add, please do. But I’d love to start by asking: What is the definition of recurrent miscarriage? When should someone seek help?

Dr. Nischelle Kalakota

Yeah, so that’s a great question to ask. In the past, they actually defined it as three or more losses, but now we’ve changed that definition, and it’s now two or more losses.

It does not have to be consecutive losses — meaning back to back — but I advise that women seek evaluation if they’ve had two or more because it’s actually a lot less common than people think.

Less than 5% of women will have two or more miscarriages. By that, I mean a pregnancy that’s been confirmed either by ultrasound or pathology, if they’ve had a procedure such as a suction D&C to remove the pregnancy contents and then those cells show pregnancy tissue.

There are some different definitions between the United States and the European Societ of Human Reproduction and Embryology. They actually base it off of even just laboratory confirmation — so having a blood pregnancy test that confirms evidence of the pregnancy hormone.

Even fewer women — less than 1% — have three or more losses.

So we definitely advise patients to come see us after two or more so that we can see what sort of factors may be corrected to prevent losses in the future. Because as I’m sure you’re going to go on to say — if you’re having IVF, you’ve worked extremely hard to get these embryos.

Eloise Edington 

Right. Of course you want to have an evaluation depending on how that journey is going. So it makes sense that you would suggest someone seeks advice after two miscarriages.

Dr. Nischelle Kalakota

Yeah, yeah. And so that is part of our specialty.

So, as you kind of asked me to before, I’m going to get into what reproductive endocrinology and infertility really entails.

We obviously help women with infertility treatments, whether that’s intrauterine insemination, ovulation induction, or IVF — the most commonly known.

But we also specialize in all the reproductive hormone disorders. So things like polycystic ovarian syndrome, endometriosis.

I see women for premature ovarian insufficiency or premature menopause, and more less commonly known — but things like mullerian anomalies, meaning developmental disorders of the female genital tract.

So we’re sort of a specialized field, but we do a lot of things within reproductive health.

Eloise Edington 

Great to know. Thank you. And as I mentioned, if anyone has any questions for Dr. Calakota as we’re discussing, please don’t hesitate to ask.

You must see many patients — as it is, of course, sadly common — who are experiencing recurrent loss. How often would you actually find a clear reason?

Dr. Nischelle Kalakota

That is a tough one. So unfortunately, not as commonly as we would like. I always preface my discussions with the patient with the fact that we only really find an etiology in 50% of cases.

We do our best to find what we call modifiable factors — so things that we can correct moving forward — but sadly in about half of the women we see, we don’t actually find anything abnormal within their evaluation.

Eloise Edington 

So if that might be the case, what would you suggest to patients when they’re having these tests and evaluations done and they’re looking for an answer and you’re working with them?

Dr. Nischelle Kalakota

Yeah. So, do you mean what we suggest in our evaluation or sort of what we suggest if nothing comes up?

Eloise Edington 

I think if nothing comes up, because I know that of course everyone wants a reason, they want an answer.

And I know that fertility and infertility can be unpredictable — so good to understand what direction people can take if those answers aren’t available.

Dr. Nischelle Kalakota

Yeah. So there is always IVF with pre-implantation genetic testing to consider. As of right now, the American Society for Reproductive Medicine does not endorse it as a treatment for recurrent pregnancy loss, and I completely agree with that statement.

We’re not treating the losses — what we’re doing is attempting to decrease the chance of miscarriage by screening for genetically normal embryos before we transfer them. So that is something that we offer patients if nothing comes up in the workup.

However, I think that the thing I like to stress to patients is: although losses are obviously very difficult to go through — both physically, emotionally — a lot of women do have a good prognosis, especially those who are young and especially those who have had a prior live birth.

They actually have over a 50% chance of having a live birth again in the future. The issue is we just don’t know how many losses you may endure getting to that point if you continue to try naturally.

Eloise Edington 

Absolutely.

Dr. Nischelle Kalakota

Yeah. So, IVF is definitely something that we discuss with patients, and I’m very forthright about the fact that it is extremely effective in decreasing miscarriage rates in older women who are more likely to have miscarriages, meaning those women closer to their 40s.

But in women who are actually younger with good egg reserve, good quality eggs, who are 35 and younger, they actually haven’t been shown to have a significantly decreased miscarriage rate with IVF.

But it is an intervention that we can use to help screen the embryos, like I said, before we put them in, because we do know that approximately 50% of pregnancy losses within the first trimester are due to abnormalities within the chromosomes.

Eloise Edington 

Do you find that it is sort of personal preference for patients whether they continue trying naturally or whether they go to IVF with PGT-A, for example?

Dr. Nischelle Kalakota

Yeah. I think it’s a combination of both a personal preference and, unfortunately, financial constraints as well, just being totally honest.

Not everyone can go forward with IVF. Not everyone has insurance coverage.

So, I think that is part of what goes into the decision-making for a couple. I also have a lot of patients who just want to continue trying but have a time limit.

They’ll tell me, “I want to try for two or three more months and then if it doesn’t work, we plan to return for IVF.”

So, I think it’s a combination of personal preference — when they feel ready to go forward with a more invasive and complex treatment like IVF versus trying naturally — and also financial constraints.

And then, of course, there sadly will be patients who have recurrent miscarriage with IVF as well.

Eloise Edington 

So how much can that help?

Dr. Nischelle Kalakota

Yeah. So, you know, that is a challenging circumstance we find ourselves in.

Thankfully, we find ourselves in that circumstance less with IVF. At that point, we sometimes will do a workup for something called recurrent implantation failure. And then also we’ll make sure their recurrent pregnancy loss evaluation is up to date.

So, we’ll make sure that they are still normal within their thyroid hormone, still not diabetic, make sure there hasn’t been any changes in their uterine cavity — meaning they now have scar tissue or fibroids that could be complicating the picture. So, we kind of just take a step back and re-evaluate if we see recurrent pregnancy loss with IVF as well.

Eloise Edington 

That makes complete sense. And in terms of genetic factors, what role do they play in recurrent loss versus other factors like you just mentioned — uterine abnormalities, immune issues, clotting disorders, for example?

Dr. Nischelle Kalakota

So, I would say that abnormalities within the chromosomal makeup of the fetus or the pregnancy is more common than when we see losses due to clotting disorders or mullerian anomalies. Clotting disorders are pretty rare.

We do always check for it because they can be related to not only loss but other obstetrical complications — things like intrauterine growth restriction, preterm delivery, preeclampsia.

So it’s important to know and screen for those as well, even if you do have a successful pregnancy that continues on, because unfortunately the risk doesn’t end there.

And I would say that would probably be the least common. More common than that would be structural abnormalities. So, we commonly will see fibroids, we will see scar tissue from people who have had prior intrauterine surgery such as C-sections, hysteroscopies, D&Cs. And then we also do see a fair number of uterine anomalies.

Most commonly is the uterine septum, which is a wall within the uterine cavity. Within women who have recurrent pregnancy loss, the prevalence for those is about 12%, versus women in the general population have about a prevalence of 4%. So, it’s like tripled in those with losses or a history of losses.

So, that’s definitely high on our list when we’re evaluating these patients.

Eloise Edington 

That’s really useful to know.

We’ve mentioned testing, but in terms of tests that you would recommend for someone who has multiple losses, are there any that are often overlooked that people might advocate for themselves and potentially get a second opinion or come to you guys for that expertise?

Dr. Nischelle Kalakota

Yeah. I would say a lot of my patients do have OB-GYNs in the general community who initiate this workup, and it can be extremely helpful to us because at least we have some results before we see the patient.

Usually, what I see my patients come to me with having had is thyroid testing, an ultrasound, diabetes testing.

Where we take it a step further is we’ll screen for a karyotype, which is looking at the genetic makeup of both partners.

This is really important because although it’s rare, there can be a condition where patients have something called a balanced translocation, which is essentially a rearrangement of the chromosomal material or the genetic material, which does not manifest itself in the patient — since they still have all the pieces, they’re fine.

But then, when they have offspring, they become rearranged in an unbalanced manner, which then leads to losses. So, I’d say this is something that may not always be tested for when the evaluation is not being done by a specialist. Something to definitely look into. It’s called a karyotype.

Additionally, we usually will do an evaluation with a specialized ultrasound called a saline infusion sonogram or a 3D ultrasound, which is essentially where we are looking within the cavity of the uterus.

I get this question a lot because a lot of patients ask me, “How is this different than the normal ultrasound that my GYN did?” And the answer is: when you have a normal just transvaginal ultrasound, the uterus is sort of collapsed on itself, and it’s difficult to see within the cavity. But when we do this specialized ultrasound, we gently distend the uterus so we can look inside.

That is really the key to determining if there’s anything within the cavity that could be affecting a pregnancy.

So, I’d say really sort of pushing for this specialized imaging and then also the karyotype evaluation is important.

Eloise Edington 

And how common would it be for you to find an issue when you’re doing that testing?

Dr. Nischelle Kalakota

It depends on their clinical history. If I have a patient who’s had multiple uterine surgeries, it’s pretty common for me to go in there and find some scar tissue that could be contributing.

If I have a patient who is telling me they also have very heavy periods, it’s pretty common for me to go in there and see a fibroid.

So, I’d say it’s kind of hard to say for the general population, but I do often find structural abnormalities — more so than I’d say a blood clotting disorder or a genetic abnormality.

Eloise Edington 

So I guess this comes back to what we were kind of discussing before, which is, based on circumstances, age, it would be worth coming to see a fertility specialist like yourself to get evaluated versus potentially waiting and potentially going through more losses that you could help with.

Dr. Nischelle Kalakota

Yeah, definitely. I would say age is a big factor with it. Part of it is just a process that — we can try our best to be as healthy as possible, but we cannot stop the clock.

Unfortunately, for women, as we get closer to our 40s, and especially beyond 40 years old, we are at a higher rate of miscarriage regardless of what our clinical history looks like. Simply because we are born with the eggs that we have.

We have our highest egg count when we are actually in our mother’s womb, and we live our life with those eggs. As we age, they do too, and so the genetic material within the eggs becomes more unstable and it’s at risk for having offspring with abnormalities.

So I definitely encourage women — seek evaluation when you have those two losses, and especially consider it sooner rather than later as you are getting closer to the age of 40 and beyond.

Eloise Edington 

Really great advice. Thank you. For anyone listening, please don’t hesitate to reach out to the team at Aspire Fertility Houston or the Prelude Network, who can help you with everything we’re discussing today. Links in the bio.

And I wanted to also ask — going back to testing — once that has happened, what are some of the most effective treatment options or management options that you might recommend as a specialist and expert in this field moving forward?

Dr. Nischelle Kalakota

Yeah. So I think our approach to treatment is obviously very targeted towards what the evaluation shows us. So if a woman has a structural abnormality, our goal is to treat that.

If they have a fibroid, then we surgically remove it. That decision of how we approach it surgically is made between the patient and myself, or a GYN surgeon if we need to get them involved.

We really strive to try to do that in a minimally invasive approach. A common procedure that I do as a reproductive endocrinologist and fertility specialist is called a hysteroscopic myomectomy, meaning we place a camera into the uterine cavity and we do everything from a vaginal approach. So you have no incisions on the abdomen.

That’s usually what we do because the fibroids that we care about in the fertility world are the ones that affect the lining of the uterus. So the best way to get at them often is from within the uterus.

If a patient has a clotting disorder — whether it’s inherited or acquired — we commonly look for antiphospholipid antibody syndrome.

The inherited disorders and their link to recurrent miscarriage are not as well described as the antiphospholipid antibody syndrome and its relationship is. Oftentimes we will still put both types of patients on blood thinners, but the reason for why we do that is a little bit different.

With those with antiphospholipid antibody syndrome, we know that we’re giving them blood thinners to help get a better pregnancy outcome, help the pregnancy continue.

For those who have inherited clotting disorders, we’re also giving them blood thinners, but more so to help prevent a blood clot in pregnancy and help maternal morbidity for them. That’s our approach for them.

If I have a woman who has a genetic abnormality — meaning one of those balanced translocations that we talked about, or Robertsonian translocation — their treatment pathway is a little bit more complex.

We involve genetic counseling, and they help us counsel this patient on a specific type of pre-implantation genetic testing that we utilize, which is called PGT-SR. In that genetic testing, we are looking for structural rearrangements within the chromosomes for the embryos. We often will pair that in addition to PGT-A, which is looking for aneuploidies or chromosomal abnormalities.

A kind of less complex issue to address is any sort of chronic medical conditions, and that is something I actually didn’t mention but we do commonly see.

Things like uncontrolled thyroid disease, uncontrolled diabetes, poorly controlled high blood pressure — all of those things we try to optimize prior to proceeding with pregnancy because we know that optimizing control of those can also help reduce miscarriage.

One of the biggest ones that’s coming to light now is the link between obesity and miscarriage. I’m not sure if many people realize, but obesity within itself is actually linked to a lot of obstetrical complications — things like preterm delivery, congenital anomalies, miscarriage, stillbirth, increased risk of C-section.

So optimizing weight as well can also help reduce your miscarriage risk.

Eloise Edington 

Really useful to know. Just going back to what you mentioned about blood thinners and blood clotting disorders — I have taken blood thinners throughout my IVF cycles and throughout pregnancy and postpartum due to having Factor V Leiden.

Is that a blood clotting disorder that you commonly see?

Dr. Nischelle Kalakota

I have actually seen one or two of those patients so far. It is one of the more common ones compared to antithrombin III or prothrombin. I believe Factor V is actually one of the most common.

There’s also the difference within that — meaning are you a heterozygote (one abnormal gene) or a homozygote (two). The homozygote usually has a higher risk for blood clots and other complications.

Eloise Edington

Interesting. And in terms of recurrent miscarriage and loss, is this something that runs in families?

Dr. Nischelle Kalakota

As of right now, I think it depends on what is the reason that you’re having the losses.

We do know that things like diabetes and thyroid disease, especially if they’re autoimmune, have a familial pattern.

But if your reason for the losses is things like antiphospholipid antibody syndrome or fibroids, we don’t really see as much of a correlation between family history and having had them.

Eloise Edington 

That’s useful to know. We just talked about testing and clear answers from testing. Anything to add from what we’ve already discussed about proactive next steps for people who might be coming to see you once testing is done?

Dr. Nischelle Kalakota

Yeah. I think a really important consideration is lifestyle factors too. Definitely looking at your own lifestyle and seeing what things might be contributing to an unhealthy lifestyle — like looking at your caffeine consumption.

We do know that there’s a slightly elevated risk of miscarriage with consumption greater than 300 milligrams per day. I believe a tall at Starbucks is around 70 to 80 — someone may have to fact-check me on that.

But having more than three cups of coffee, consuming more than a few drinks a week in terms of alcohol consumption — usually I try to recommend to my patients to keep it at about two or three drinks per week or less.

Smoking, cigarette smoking, tobacco use is linked to not only miscarriage but also obstetrical complications.

And as I said before, obesity — so BMIs within the obese range — women who fit in that category are at a higher risk for miscarriage. Considering your lifestyle factors is also a change that can be made before you even come see us.

Eloise Edington

Okay, that’s really, really useful to know. You’ve mentioned PGT-A, so genetic testing of embryos. In terms of this fitting into the picture for recurrent loss, is this something that you would recommend to most patients as standard care or is this particularly relevant for people who have been experiencing recurrent loss, versus those who haven’t?

Dr. Nischelle Kalakota

So, it’s not something that I recommend for standard care to all patients. The data has shown benefit in terms of improving miscarriage rates in those who are older — so older than the age of 35.

When I have a woman who comes to me for IVF below the age of 35 — whether it’s unexplained infertility, male factor, she had frozen her eggs before and now wants to utilize them — I don’t necessarily push hard for PGT-A in younger women. I think a lot of providers are kind of the same.

Obviously I can’t speak for everyone, but because a woman who’s younger is more likely to have better quality eggs and a lower miscarriage rate at baseline, we don’t necessarily advocate aggressively for PGT-A. But as we have women who are older and at higher risk just at baseline for chromosomal abnormalities, we do strongly recommend PGT-A at that point.

Eloise Edington 

Okay.

Dr. Nischelle Kalakota

I tell patients: if family balancing is important to you — meaning having a child of a certain sex — then that answer can only be given to you through PGT-A.

I also think that something functionally to keep in mind is that it does help you prioritize the embryos for transfer. I wish all of us had unlimited resources, but that’s not the case.

We do know that a genetically normal embryo has a higher chance of implanting. So that can also help you choose which embryos to start with. But again, it’s not necessary. We can also make that decision based on embryo morphology — meaning the grading — too.

Eloise Edington

Great advice. Thank you so much for sharing this. We’ve mentioned lifestyle, nutrition — any kind of mental health considerations that can support people after a loss or multiple losses? How does the clinic support patients with this?

Dr. Nischelle Kalakota

Yeah, you know, I think that’s a great question. A lot of people don’t really realize how much of a psychological toll that infertility, losses, all of this can take on a woman, especially when she’s also trying to handle the normal stressors of life and now has this on top of that.

So, as a clinic, we try our best to check in with these patients, whether it’s myself or my nursing staff, offer whatever support that we can offer in however capacity.

Whenever I see women come to me after this, I try to explain that so little of this, unfortunately, is in our control. A lot of women feel bad like it’s something that they did intentionally, especially if it’s an IVF failure.

But we don’t have 100% control — that’s just the reality of it. We try to do our best, but even science gets us to about a 65%, maybe even 70% chance of success with a genetically normal embryo that’s good quality, but we’re not at 100%.

So, there are things that are out of our control. I think just being there for the woman and recognizing that this is a difficult process — it can be anxiety-provoking — and just kind of listening can help.

I do recommend, if a patient feels like they need additional help, seeking counseling, especially because this can be hard on a couple too, not only the patient who’s going through it.

It’s definitely a stressful process, and also it’s useful for family and friends to understand how to best support people in this situation — what to say, what not to say, triggers, all kinds.

Eloise Edington

Is this counseling available at Aspire?

Dr. Nischelle Kalakota

So, it is not available at Aspire here. We don’t have counseling like that yet. We usually just recommend patients seek psychological counseling or talk to their primary care provider.

Unfortunately, we don’t have anything specialized yet, but that is a great idea for maybe practice expansion.

But it’s good just to have these conversations, isn’t it? And even to have your expertise when it comes to the holistic nutritional side as well, so patients are informed on what to look for and why that might be important during this journey and beyond.

Sometimes I’ve had this conversation with my patients, and they seek some solace in being able to have control over things that they can control — whether it’s making changes in their lifestyle choices, deciding they want to start exercising — and sometimes focusing on that can also help them in their healing.

Eloise Edington 

You must see a lot of anxious patients who have experienced early loss, for example, coming to you for those early scans just holding their breath, crying as a heartbeat…

Dr. Nischelle Kalakota

Yeah. We do. And we’re holding our breath with them because we know how anxiety-provoking it can be.

And in kind of what you were saying — what to say and what not to say — I think a lot of these women unfortunately are probably hearing things that maybe shouldn’t be said. So, we try to do our best to maybe say less, just be there as support.

Eloise Edington 

That’s fantastic to hear. And then finally, for anyone who is struggling to get the right care and answers, how can they best advocate for themselves? What’s your advice here with their doctor, OB/GYN, or coming to yourselves as an expert fertility team?

Dr. Nischelle Kalakota

Yeah. We do take self-referrals. But I would also recommend, if you want to talk to your OB/GYN, just tell them, “I think I would like to see a specialist. I would like to see an infertility specialist,” and maybe get that ball rolling.

I have a lot of young women who actually come to me saying, “I’m not even trying to conceive yet, but I plan to within the next year. I’d like to undergo some testing before I start that journey.”

So I think seeing examples like that — of women advocating for themselves even before they find themselves with infertility or pregnancy loss — is helpful and can maybe give you some answers.

Eloise Edington 

Great advice. For anyone who is struggling, looking for answers, looking for a second opinion, looking for a first opinion — especially prevalent right now in National Infertility Awareness Week and ongoing — please do head to our link in bio to find the nearest Prelude Network clinic to you. Connect with their team of experts who will be more than happy to help you on your path to supporting your needs, goals, parenthood, etc.

Thank you so much for your time today, Doctor. It’s been lovely chatting with you.

Dr. Nischelle Kalakota

Yes, same to you. Thank you so much.

Bye.

Eloise Edington

Bye.

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