Recurrent Pregnancy Loss (RPL)

Recurrent pregnancy loss means losing two or more pregnancies. The European Society of Human Reproduction and Embryology (ESHRE) defines RPL as the loss of two or more pregnancies, counting confirmed pregnancies but excluding ectopic and molar pregnancies. It affects roughly 1-2% of couples trying to conceive, with wider literature putting the figure as high as 2-5% depending on the definition used.

An older view required three consecutive losses before any testing. That has changed. Most clinics now begin investigating after two losses, because waiting longer rarely changes the eventual answer and only adds distress.

RPL is defined as two or more pregnancy losses. It is more common than most people realise, and the majority of couples go on to have a healthy baby. Investigation after two losses is reasonable, and finding no cause is itself common and not a reason to lose hope.

The single most common cause of an individual loss is a chromosomal error in the embryo. Around 50-70% of sporadic first-trimester miscarriages carry a chromosomal abnormality, usually aneuploidy that happens by chance and rises with maternal age. These errors are not inherited and not anyone's fault.

Beyond chance aneuploidy, identifiable contributors include parental chromosome rearrangements (such as a balanced translocation), uterine anomalies (for example a septate uterus), antiphospholipid syndrome (APS), and thyroid or other endocrine problems. Thrombophilia is a caveat: apart from APS, inherited clotting disorders have weak and inconsistent evidence as a cause of RPL, so routine treatment with blood thinners for them is not supported. In about half of couples, no cause is found despite a full workup. This is called unexplained RPL.

Most miscarriages reflect a chance chromosomal error in that single embryo, not a fixed problem that will repeat. Finding no cause after testing is common, and the outlook is still good.

RPL itself is defined by the pattern of repeated loss rather than by day-to-day symptoms. Between pregnancies, most women feel completely well and have normal cycles. The condition is recognised from the history of two or more losses, not from a single warning sign.

During an individual miscarriage, the usual signs are vaginal bleeding and cramping, though some losses are found on a scan before any symptoms appear. The heaviest burden of RPL is often emotional. Anxiety, grief, and low mood are common and deserve care alongside the medical workup.

Diagnosis aims to find a treatable cause without over-testing. ESHRE recommends a focused workup after two losses rather than a long list of unproven tests. The core checks are screening for antiphospholipid syndrome, assessing the shape of the uterus, and testing thyroid function.

Parental karyotyping is offered selectively, for example after a loss with an abnormal fetal karyotype or with a relevant family history, rather than for everyone. Testing the pregnancy tissue (products of conception) can show whether a chromosomal error explained that loss, which often brings reassurance. Many widely marketed tests add cost without changing care, so a measured approach matters.

Standard Diagnostic Tests in India

• Antiphospholipid syndrome (APS) screening — Blood tests for lupus anticoagulant, anticardiolipin, and anti-beta-2 glycoprotein antibodies, repeated to confirm.
• Uterine assessment — Ultrasound, often 3D, or hysteroscopy to look for a septum or other structural anomaly that may be correctable.
• Thyroid function tests — TSH and thyroid antibodies, since thyroid dysfunction is a treatable contributor to pregnancy loss.
• Parental karyotyping (selective) — Chromosome analysis of both partners, offered when history or a prior abnormal fetal result suggests a rearrangement.
• Products of conception testing — Genetic testing of pregnancy tissue can reveal whether a chromosomal error explained a particular loss.

RPL usually affects the ability to carry a pregnancy rather than the ability to conceive. Many couples with RPL get pregnant readily; the difficulty is in the pregnancy continuing. The strongest predictors of outcome are maternal age and the number of previous losses.

The encouraging part is the prognosis. Even after unexplained RPL, a large share of couples have a successful next pregnancy, with reported live-birth rates of roughly 50-70% that depend heavily on age and history. Younger women with fewer prior losses sit at the higher end. This is why supportive, expectant care is a legitimate and often successful path.

• Conception is often normal: Many couples with RPL conceive easily; the challenge is in the pregnancy continuing, not in getting pregnant.
• Maternal age matters most: Rising age increases chance chromosomal errors in eggs, raising both miscarriage risk and time to a healthy pregnancy.
• Prior loss count affects odds: Each additional previous loss modestly lowers the chance of the next pregnancy succeeding.
• Good overall prognosis: Even with unexplained RPL, roughly 50-70% of couples achieve a live birth in the next pregnancy, depending on age and history.
• Emotional impact on care: Distress can affect decision-making, so counselling and supportive monitoring are part of fertility care, not extras.

The guiding principle is to treat an identified cause and avoid treatments that are not proven. When antiphospholipid syndrome is confirmed, the combination of low-dose aspirin and heparin improves live-birth rates; in one classic study live births rose from 44% with aspirin alone to about 80% with the combination. A significant uterine septum may be corrected surgically, and thyroid dysfunction is treated to bring levels into the target range.

Be cautious about unproven therapies. Immune treatments, steroids, and clot-prevention drugs for inherited thrombophilia (outside APS) lack good evidence in RPL and can carry real risks and costs. For unexplained RPL, supportive care with close early-pregnancy monitoring is appropriate and frequently ends in a live birth.

IVF is not a default fix for RPL, since most couples can conceive naturally. IVF combined with preimplantation genetic testing for aneuploidy (PGT-A) is sometimes suggested to select chromosomally normal embryos, and it can lower the chance of miscarriage per transfer. The important nuance is that high-quality evidence it improves the cumulative chance of a live baby in RPL is lacking, and it is not routinely recommended.

IVF with PGT-A has clearer logic when there is a known parental chromosome rearrangement or when age strongly drives aneuploidy. Set realistic expectations: PGT-A reduces transfers that fail, but it does not create more healthy embryos than your eggs can produce, and randomised trials against simply trying again are still awaited.