Written by Tatiana Vazquez De Los Santos, MD, and C. Peony Khoo, MD

Recurrent pregnancy loss (RPL) – defined as 2 or more spontaneous pregnancy losses – has a prevalence of at least 2%.¹ Discrepancies exist between couples’ and medical professionals’ perceptions of pregnancy loss.² For example, couples surveyed in one study out of Denmark expressed desire for earlier access to testing rather than waiting for a third pregnancy loss before being able to seek specialized care.² The 2026 update of the American Society for Reproductive Medicine (ASRM) committee opinion on recurrent pregnancy loss makes strides towards a more patient-centered approach by lowering the evaluation threshold to two losses (including biochemical and non-consecutive), recommending genetic testing of products of conception as a first step in evaluation, and emphasizing psychological support in miscarriage care.³ Select recommendations from the 2026 ASRM update are included below.

Evaluation of RPL

Chromosomal analysis and uterine cavity evaluation can be considered for all patients with RPL. Aneuploidy, an abnormal number of chromosomes, is identified in approximately 50-60% of first trimester pregnancy losses. Patients with RPL are more likely to have euploid (normal number of chromosomes) miscarriages compared to patients with one pregnancy loss. Chromosome analysis of miscarriage tissue with array-based testing is suggested by ASMR and other professional organizations. Discussion of home-based collection of tissue should be initiated at the time of miscarriage for patients who do not want surgical management. Testing of the products of conception (POC) may reduce feelings of guilt and self-blame. Additionally, screening for parental balanced structural chromosomal rearrangements should be done if products of conception are not available for testing or if unbalanced structural chromosome rearrangement is detected in POC. ASRM recommends uterine cavity evaluation with hysterosalpingography, saline sonogram, or hysteroscopy for all patients with RPL to evaluate for potential contributors to and sequelae of recurrent pregnancy loss. Screening for hypothyroidism is recommended for those with risk factors or symptoms, euploid miscarriage, or no miscarriage testing. Further evaluation of RPL should be tailored to the patient based on medical history and may include screening for diabetes, hypothyroidism, antiphospholipid syndrome (APS), and hyperprolactinemia in those with signs/symptoms or meeting clinical criteria. 

Management of RPL

The updated guidance recognizes that management must be individualized for each patient. Given the association with certain exposures to miscarriage, lifestyle interventions are recommended although data on efficacy of these interventions are limited. Smoking cessation is strongly recommended. The ASRM committee opinion acknowledges limited evidence on these interventions but, due to their identification as risk factors, suggests that weight optimization and limiting alcohol and caffeine intake may have a role. Treatment of existing conditions such as overt thyroid disease (TSH >4 mIU/L), uncontrolled diabetes, APS, and hyperprolactinemia with ovulatory dysfunction is recommended.

Practical takeaways for reproductive care clinicians

The ASRM committee opinion addresses important updates for consideration by clinicians. Key takeaways and ways to integrate these recommendations practically are summarized in Table 1.