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Recurrent pregnancy loss

ASRM 2026 definition, evidence-based staged evaluation, cause-directed treatment and prognosis after recurrent pregnancy loss.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team · Clinical editorial review · reviewed 2026-08-20 · due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Patients with two or more pregnancy losses as defined by the 2026 ASRM committee opinion, including biochemical pregnancies confirmed by urine or serum human chorionic gonadotropin. Ectopic and molar pregnancies are excluded, and an acute current loss requires immediate pregnancy-location and stability assessment first.
sources for this section:ASRM RPL 2026

The Bottom Line

  • Begin recurrent-pregnancy-loss evaluation after two or more losses and use the 2026 definition rather than requiring three clinical ultrasound-confirmed miscarriages.
  • A staged evaluation considers genetic causes, uterine anatomy, antiphospholipid syndrome and selected endocrine or metabolic factors while being guided by the sequence, gestational timing and prior results.
  • Testing pregnancy tissue for chromosomal abnormalities can be informative; parental karyotyping is selective rather than an automatic first test for every couple.
  • Do not routinely order inherited-thrombophilia panels, natural-killer-cell assays, thyroid-antibody panels, microbiome tests or other unsupported investigations simply because losses remain unexplained.
  • Even when no cause is found, subsequent live-birth probability is often favorable and varies with age and pregnancy history; communicate uncertainty without promising an outcome.
sources for this section:ASRM RPL 2026

Practical clinical workflow

1
Verify each pregnancy and outcome, including biochemical results, gestational age, imaging, pathology, prior chromosome testing, ectopic or molar diagnoses and treatment complications.
2
Take a three-generation family and reproductive history and review uterine procedures, thrombosis, autoimmune disease, endocrine symptoms, medicines, exposures and both partners’ relevant history.
3
Prioritize evaluation of the uterine cavity and evidence-based genetic and antiphospholipid questions, adding thyroid or other targeted tests when the history and current ASRM algorithm support them.
4
Treat an identified cause using its source-supported pathway: for example, coordinate genetic counseling for chromosomal findings and aspirin plus heparin for appropriately diagnosed obstetric antiphospholipid syndrome.
5
Plan early contact and pregnancy monitoring in a future conception, provide grief and mental-health support, and revisit the value and burden of further testing through shared decisions.
sources for this section:ASRM RPL 2026

Safety boundaries and escalation

  • Pain, syncope, shoulder pain or heavy bleeding in a current pregnancy requires urgent ectopic and hemorrhage assessment; a history of recurrent loss must not anchor the diagnosis on another miscarriage.
  • Do not prescribe empiric anticoagulation, glucocorticoids, intravenous immunoglobulin or other immune treatment without a supported indication because treatment burden and bleeding or metabolic harms are real.
  • A molar pregnancy, suspected retained tissue, infection or severe anemia requires its own urgent follow-up and must not be counted or managed as routine unexplained recurrent loss.
  • Depression, trauma symptoms, relationship strain and suicidality can follow repeated losses; actively assess wellbeing and connect urgent risk to immediate support rather than offering reassurance alone.
sources for this section:ASRM RPL 2026

Localization

This US page uses the new ASRM 2026 committee opinion, which changes the diagnostic definition and testing algorithm from the retired 2012 opinion. Genetics access, insurance authorization and state pregnancy-care restrictions vary and must not delay emergency treatment.
sources for this section:ASRM RPL 2026

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American Society for Reproductive Medicine Practice CommitteeRecurrent pregnancy loss: a committee opinionFertil Steril 2026;125:1023–1041 · published 2026-06-01 · accessed 2026-08-20
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