How does RRM approach recurrent miscarriage (RPL)?

RRM approaches recurrent pregnancy loss (RPL) through systematic evaluation of genetic, anatomic, endocrine, immune, and male factors, followed by targeted treatment based on evidence-based protocols including progesterone support when indicated.

Understanding Recurrent Pregnancy Loss

Recurrent pregnancy loss affects 2-5% of couples trying to conceive. The 2022 ESHRE guideline defines it as the loss of two or more pregnancies and leaves the timing of investigations to shared decision-making between the doctor and the couple. Evaluation can begin after the second loss. Couples who have experienced this devastating pattern are often told "it's just bad luck" and sent home without further investigation.

RRM takes a systematic approach because RPL often has identifiable, treatable causes. Rather than accepting pregnancy loss as inevitable, RRM clinicians investigate the underlying factors that may be preventing successful pregnancy maintenance.

Systematic RRM Evaluation

An RRM evaluation commonly covers several key areas. The exact tests vary by clinician, by method, and by each couple's history. Genetic assessment can include parental karyotyping. Anatomic evaluation can use hysteroscopy or specialized imaging to look at uterine structure for a septum, fibroids, or adhesions that may interfere with implantation or early pregnancy development.

Endocrine assessment often goes beyond basic hormone panels and may include thyroid function, screening for undiagnosed insulin resistance, and progesterone production quality. Immune and infectious evaluation may include screening for antiphospholipid syndrome, inherited thrombophilias when clinically indicated, and chronic endometritis. Male factor evaluation can include sperm DNA fragmentation testing, as evidence suggests damaged sperm DNA may contribute to early pregnancy loss.

Evidence-Based Treatment Approaches

Treatment is tailored to identified causes. The PRISM trial (Coomarasamy et al., 2019) provided important evidence for progesterone supplementation in women with early pregnancy bleeding and one or more previous miscarriages. This large randomized controlled trial showed progesterone support increased live birth rates in this group, with the largest benefit after three or more losses.

• PRISM trial (Coomarasamy et al., 2019): Progesterone supplementation increased live births in women with early bleeding and one or more previous miscarriages (72% vs 57% live births at 34 weeks or later after three or more losses)
• ESHRE guideline, 2022 update (Bender Atik et al., 2023): Defines recurrent pregnancy loss as the loss of two or more pregnancies; when to start investigations is a shared decision between the doctor and the couple
• Thrombophilia screening: Indicated in specific clinical scenarios, not routinely

RRM's Distinctive Approach

RRM's commitment is thorough investigation rather than empirical treatment. The label "unexplained" is not accepted until evaluation is complete. When treatable conditions are identified, such as thyroid dysfunction, anatomic abnormalities, or chronic endometritis, clinicians address these systematically.

The couple-centered approach recognizes that both partners contribute to pregnancy success. RRM clinicians provide transparent information about what the evidence supports and what remains uncertain, allowing couples to make informed decisions about their care based on their individual circumstances and values.

RRM's systematic evaluation of recurrent pregnancy loss identifies treatable causes and guides evidence-based interventions, offering couples a thorough alternative to the "just keep trying" approach.

This information is educational and not a substitute for individualized medical care. Consult an RRM clinician or healthcare provider for guidance specific to your situation.