The association between miscarriage and fecundability: the Norwegian Mother, Father and Child Cohort Study

Abstract

Study question: Is fecundability associated with miscarriage history and future miscarriage risk?

Summary answer: Prior miscarriage was associated with lower fecundability, and participants with a history of subfertility (time-to-pregnancy (TTP) ≥12 months) were at a higher risk of subsequent miscarriage.

What is known already: Although miscarriage and low fecundability share common risk factors, prior studies have reported both lower and higher fecundability after miscarriage.

Study design, size, duration: In this study, we examined two related associations: one, between miscarriage history and subsequent fecundability and, two, between fecundability and miscarriage risk in the subsequent pregnancy. The study is based on the Norwegian Mother, Father and Child Cohort Study (MoBa). In addition, the outcome of the pregnancy after the MoBa index pregnancy was obtained by linking information from three national health registries: the Medical Birth Registry of Norway, the Norwegian Patient Registry and the general practice database.

Participants/materials, setting, methods: We examined the association between number of prior miscarriages and fecundability in 48 537 naturally conceived, planned pregnancies in participants with at least one prior pregnancy. We estimated fecundability ratios (FRs) and 95% CIs using proportional probability regression. We further estimated the relative risk (RR) of miscarriage in the subsequent pregnancy as a function of TTP in the MoBa index pregnancy for 7889 pregnancies using log-binomial regression. Multivariable analyses adjusted for maternal age, pre-pregnancy maternal BMI, smoking status, cycle regularity, income level and highest completed or ongoing education.

Main results and the role of chance: Fecundability decreased as the number of prior miscarriages increased. The adjusted FRs among women with one, two and three or more prior miscarriages were 0.83 (95% CI: 0.80-0.85), 0.79 (95% CI: 0.74-0.83) and 0.74 (95% CI: 0.67-0.82), respectively, compared with women with no prior miscarriages. Compared to women with a TTP of <3 months, the adjusted RR of miscarriage in the subsequent pregnancy was 1.16 (0.99-1.35) with TTP of 3-6 months, 1.18 (0.93-1.49) with TTP of 7-11 months and 1.43 (1.13-1.81) with TTP of 12 or more months.

Limitations, reasons for caution: Information on TTP and prior miscarriages was obtained retrospectively, and TTP was self-reported. MoBa is a pregnancy cohort, and findings may not be generalizable to all women. We were unable to examine the effect of changing partners between pregnancies, as well as other paternal factors such as seminal parameters. We also did not know what proportion of our participants had changed partners between their prior pregnancies and the index pregnancy. Furthermore, it is likely that many early miscarriages are not recognized.

Wider implications of the findings: The association between miscarriage and fecundability may reflect a contribution of occult pregnancy losses to TTP, as well as shared underlying causes for reduced fecundability and miscarriage.

Study funding/competing interest(s): The study was funded by the Research Council of Norway through its Medical Student Research Program funding scheme (project number 271555/F20), its Centres of Excellence funding scheme (project number 262700) and through the project 'Women's fertility - an essential component of health and well-being' (project number 320656). M.C.M. has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme (grant agreement number 947684). A.J.W. is supported by the Intramural Program of the National Institute of Environmental Health Sciences at the National Institutes of Health, USA. The authors report no competing interests.

Trial registration number: N/A.

Keywords: Father and Child Cohort Study; Medical Birth Registry of Norway; Norwegian Mother; fecundability; miscarriage; subfertility; time-to-pregnancy.

Figure 1.

Illustration of inclusion criteria for the two analytic designs. MoBa, Norwegian Mother, Father and Child Cohort Study; TTP, time-to-pregnancy.

Figure 2.

Association between number of prior miscarriages and fecundability: results of sensitivity analyses.  ¹N = 3186 participants with TTP >12 excluded. ²N = 9259 otherwise eligible participants with unplanned pregnancies included, setting their TTP to 1. ³N = 11 502 participants with a self-reported TTP of 1 excluded, as there may be non-planners who reported a TTP in this group. ⁴N = 4963 reporting «3 or more», but not their exact TTP, excluded. ⁵N = 1306 participants reporting one or more completed pregnancies within their estimated TTP excluded. ⁶N = 23 283 participants whose reported TTP started between January and June excluded, as they may have had unidentified pregnancies within their TTP due to only the year of the prior pregnancies being reported. ⁷Adjusted for pre-pregnancy endocrine conditions (diabetes mellitus type 1 and 2, hyperthyroidism and hypothyroidism), autoimmune conditions (celiac disease, systemic lupus erythematosus, multiple sclerosis and rheumatoid arthritis) and gynecological conditions (endometriosis and ovarian cysts). ⁸Adjusted for paternal age at the time of conception of the MoBa index pregnancy as a linear and squared term.