ASRM 2026 Guideline: Two Miscarriages Are Enough to Start RPL Testing

On April 29, 2026, the American Society for Reproductive Medicine (ASRM) released its updated Committee Opinion on recurrent pregnancy loss (RPL). The new guideline makes one thing clear: two losses are enough to start a full medical workup. You do not have to wait for a third.

This is the first major revision in 13 years. Below is what you need to know; from the new definition to recommended tests, treatment options, and how CEF can help.

What Changed?

ASRM now defines RPL as two or more pregnancy losses before 22 weeks. The losses do not need to be consecutive. Importantly, biochemical pregnancies (confirmed by blood or urine hCG) count toward the total.

About 1% of women experience three or more losses. Under the new definition, the prevalence rises to approximately 5%, meaning 1 in 20 women qualify for RPL testing.

Previously, many guidelines required three or more losses before starting a full workup. Lowering the threshold to two means millions of women no longer have to endure the emotional toll of “just try one more time.”

What Tests Does ASRM 2026 Recommend?

Below is a practical breakdown of what to do, and what to skip.

Strongly Recommended

1. Genetic testing of pregnancy tissue for all RPL patients. Preferred methods: SNP microarray, aCGH, or NGS (abnormality detection rate 75-86%). Avoid traditional karyotyping or FISH.

2. Uterine cavity evaluation for all RPL women (3D ultrasound is the preferred imaging method).

3. Preconception health optimization: manage chronic diseases, take folic acid, stop smoking. Obesity, high alcohol intake, intense exercise, and high caffeine intake are associated with increased miscarriage risk.

4. Emotional support: The guideline explicitly states that early pregnancy monitoring and emotional support are associated with higher live birth rates, even without medication.

May Be Considered (case-dependent)

1. Antiphospholipid syndrome (APS) screening after two losses. Untreated APS carries a fetal loss rate up to 90%. Diagnosis requires persistent antibody positivity on two or more tests at least 12 weeks apart.

2. Thyroid function (TSH): Untreated hypothyroidism can raise miscarriage risk to 60%. Target TSH <2.5 mIU/L.

Other considerations

1. Chronic endometritis: prevalence 7-57% in RPL patients; may be evaluated on a case-by-case basis.

2. Male factors: paternal age and metabolic health correlate with miscarriage risk, but routine semen analysis parameters are not predictive.

Not Routinely Recommended

1. Routine inherited thrombophilia screening (without personal/family history).

2. IVIg (intravenous immunoglobulin).

3. Paternal leukocyte immunotherapy.

4. Routine NK cell testing (insufficient evidence).

From Diagnosis to Action: What Treatment Works?

Testing is only useful if it leads to effective intervention. Here is what ASRM’s recommendations translate into for patients pursuing IVF or future pregnancies:

For couples with a history of RPL and a suspected genetic cause, PGT-A can screen for chromosomally normal embryos, reducing the chance of another loss due to aneuploidy.

This is a core service that CEF helps coordinate through its partner IVF clinics in Thailand, the US, and other destinations.

Emotional Support Is Medical Support

The ASRM guideline makes an important statement: psychological and emotional support is part of evidence-based care. Women with RPL experience significantly higher rates of anxiety, depression, and post-traumatic stress symptoms. The guideline recognizes that early monitoring and compassionate care directly improve outcomes.

At CEF, we believe that fertility care must address both the science and the person. We are here to help you navigate testing, treatment, and the emotional journey; without judgment, and without asking you to “try one more time alone.”

How CEF Can Help You

1. Comprehensive RPL evaluation: We help you identify which tests from the ASRM 2026 guideline are relevant to your situation.

2. PGT-A coordination: Connect you with our experienced IVF clinic for embryo genetic screening.

3. Personalized IVF planning: Tailored stimulation, transfer protocols, and adjunct medications based on your RPL profile.

4. Second opinion / expert consultation: One-on-one virtual or in-person sessions (in select cities).

5. Emotional support resources: Referrals to fertility-friendly mental health professionals.

>For questions about RPL and your next steps, please email us at info@cefivf.com or visit our Contact page.  

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FAQs

1. I have had two miscarriages. Do I really need to wait for a third to start testing?

No. According to the 2026 ASRM guideline, two losses are sufficient to begin a full RPL workup. Do not wait.

2. Does a biochemical pregnancy count as a loss?

Yes. ASRM explicitly includes biochemical pregnancies confirmed by blood or urine hCG.

3. Is genetic testing of the miscarriage tissue necessary?

ASRM strongly recommends it. It can determine whether the loss was due to a chromosomal abnormality and guide whether PGT-A would be beneficial.

4. What if all my test results are normal?

That is a diagnosis of unexplained RPL. While frustrating, it means you have ruled out treatable causes. The guideline supports early pregnancy monitoring and emotional support as effective next steps.