Two or more losses deserve answers, not "just try again." The evidence-based workup, the causes we can actually treat, and the honest reassurance in the numbers.
✍️ By Dr. Patsama Vichinsartvichai, MD, MClinEmbryol, EFOG-EBCOG, EFRM-ESHRE/EBCOG, FACOG — Reproductive Medicine Specialist · Updated August 2026
Modern guidelines (ESHRE and ASRM) define recurrent pregnancy loss (RPL) as two or more pregnancy losses — you do not need to wait for a third miscarriage before being evaluated. About 1–2% of couples trying to conceive are affected.
Even after multiple losses, most couples eventually have a successful pregnancy. After two miscarriages the chance the next pregnancy succeeds is still roughly 70–75%; even after three it remains around 60–65%. Evaluation is about finding the treatable minority of causes — and providing proper monitoring and support, which itself is associated with better outcomes.
RPL attracts more unproven tests than almost any area of fertility medicine. An evidence-based evaluation includes:
The first-line test for uterine shape — it reliably distinguishes a septate or T-shaped cavity from a normal one. How 3D-TVUS works.
Lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein I — confirmed on two occasions 12 weeks apart before the diagnosis is made.
Simple blood tests for treatable endocrine contributors.
Considered for both partners, particularly when losses occurred early or there is a family history.
Direct confirmation and treatment of cavity findings — septum resection or hysteroscopic metroplasty for a dysmorphic uterus — via no-touch digital hysteroscopy.
Routine testing for inherited thrombophilia, natural killer cells, or extensive immune panels is not supported by current evidence and is not part of a guideline-based workup — we'll tell you that plainly rather than sell it.
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Current ESHRE and ASRM guidance supports evaluation after two pregnancy losses — you don't need to wait for a third. If you're anxious after any loss, a consultation to review your individual situation is always reasonable.
Chromosomal abnormalities in the embryo are the most common cause overall, and their likelihood rises with maternal age. Among treatable causes, uterine cavity abnormalities and antiphospholipid syndrome are the most important to find.
A 3D transvaginal ultrasound of the uterine cavity, antiphospholipid antibodies (confirmed twice, 12 weeks apart), thyroid function and prolactin, and consideration of parental karyotyping. Extensive immune panels and routine inherited-thrombophilia testing are not supported by evidence.
Yes. A uterine septum is a well-established cause of loss, and a dysmorphic (T-shaped) cavity is associated with both infertility and miscarriage. Both are diagnosed with 3D ultrasound and can be corrected with outpatient hysteroscopic surgery.
Better than most couples fear. Even after three losses without a specific cause found, roughly 60–65% of next pregnancies succeed — and higher with a treatable cause corrected and structured early-pregnancy care.
Dr. Patsama Vichinsartvichai, MD, MClinEmbryol, EFOG-EBCOG, EFRM-ESHRE/EBCOG, FACOG is a board-certified reproductive endocrinology & infertility specialist, former head of the Vajira IVF unit at Navamindradhiraj University, and founder of LIFE by Dr. Pat in Bangkok. His published research focuses on the dysmorphic (T-shaped) uterus and uterine-factor infertility.
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