What does a recurrent pregnancy loss evaluation include now?
A recurrent pregnancy loss evaluation now follows a clear order. ASRM’s 2026 committee opinion recommends starting with the tests most likely to explain the losses, then adding others based on those results and your history.
The core evaluation:
- Chromosome testing of the pregnancy tissue, when tissue is available, preferably with array-based testing.
- A uterine cavity evaluation for everyone, using a saline ultrasound, hysteroscopy, or hysterosalpingogram, to look for polyps, fibroids, scarring, or a difference in the shape of the uterus.
- TSH, the main thyroid test, for women whose losses had normal chromosomes or were not tested. ASRM recommends treatment when TSH is above 4 mIU/L or above the lab’s upper limit of normal.
- Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, and anti-beta-2 glycoprotein I) after three or more losses or a personal history of blood clots.
- HbA1c, a diabetes test, when risk factors are present, such as a higher body weight, family history, age over 40, PCOS, or past gestational diabetes.
Other tests are added selectively, depending on what these show.
Why is testing the pregnancy tissue now the first step?
Testing the pregnancy tissue comes first because it explains more losses than any other test and decides what to look at next. Between 50 and 60 percent of first-trimester miscarriages are caused by a chromosome error in the embryo, according to ASRM’s 2026 guidance.
The result points the evaluation in one of two directions:
- An abnormal chromosome result explains that loss. It is usually a one-time event, more common with age, and the outlook for a future pregnancy is generally good.
- A normal chromosome result means something outside the embryo may be involved, so the uterus, thyroid, blood clotting, and blood sugar become more important to check.
ASRM also notes that in women with recurrent loss, the share of losses with normal chromosomes rises with the number of losses, which is why the result matters more with each pregnancy.
Array-based testing is preferred over traditional karyotyping because it does not depend on growing cells in a lab, which can fail, and some versions can detect when a sample contains the mother’s cells instead of the pregnancy’s.
Which tests are no longer recommended routinely, and why?
ASRM’s 2026 guidance advises against several tests that are still widely offered after recurrent loss, because they either do not predict outcomes or lead to treatments that have not been shown to help.
Not recommended routinely after recurrent loss:
- Inherited thrombophilia panels, such as factor V Leiden or prothrombin gene testing, because these variants are no more common in women with recurrent loss than in the general population.
- Thyroid antibodies, because treating antibody-positive women with normal thyroid levels has not improved outcomes.
- Natural killer cell, endometrial receptivity, and microbiome testing, and routine immune panels.
- Ovarian reserve testing, such as AMH, as a way to explain loss.
- Prolactin, unless there are symptoms such as irregular ovulation or nipple discharge.
ASRM also advises against blood thinners such as aspirin or heparin for unexplained recurrent loss, and against embryo testing during IVF for everyone with recurrent loss.
None of this means your concerns are wrong. It means your time, money, and hope are better spent on the tests that can change what happens next.
When does my partner need testing too?
Your partner needs testing in specific situations rather than routinely. ASRM’s 2026 guidance recommends a karyotype, a test of both partners’ chromosomes, when tissue testing shows an unbalanced chromosome rearrangement, or when no tissue testing was available.
A karyotype looks for a balanced translocation, where pieces of two chromosomes have swapped places. A person with a balanced translocation is healthy, but some of their embryos may receive an unbalanced set of chromosomes, which can cause a loss. Even then, ASRM reports live birth rates as high as 70 to 71 percent for carriers without assisted reproduction.
ASRM also says sperm DNA fragmentation testing may be considered when losses remain unexplained or when there is also infertility, while noting that more research is needed to know whether treatment improves outcomes.
Beyond tests, your partner belongs in this process. ASRM notes that male partners experience depression and anxiety after loss, often with less support than women receive.
How do I bring this list to my appointment without feeling dismissed?
Bring the list as a shared reference, not a demand. Saying “I read ASRM’s 2026 guidance on recurrent loss, and I’d like to understand which of these steps I’ve had” invites your doctor to work through it with you.
Before the appointment:
- Write down every pregnancy with the date, the week of the loss, and how it was confirmed.
- Request copies of past results, including the actual numbers, not just “normal.”
- Mark each item on the evaluation list as done, not done, or not sure.
In the appointment, ask about the gaps one at a time. If a test is declined, a respectful follow-up keeps the door open: “Can you help me understand why that one doesn’t apply to me?”
If your concerns are repeatedly brushed aside, a second opinion from a reproductive endocrinologist who sees recurrent loss regularly is a reasonable step. You are not being difficult. You are asking for the standard of care.
From Heather
What I remember being tested, and what I don't.
When I look back at my own testing, a lot of it came back normal. My hormones were in range, except my AMH, which was low. I had a baseline thyroid test. Genetic carrier screening came back clear on all 222 conditions it checked. My husband had a semen analysis. After my myomectomy, my fibroids were rechecked and my uterine lining was scanned.
What I don’t recall ever being asked about is a fuller look at my thyroid, my ferritin, or my T3 and T4. And none of my four losses had tissue testing.
I’m not saying those gaps caused my losses. No one can know that now. I’m saying my record had gaps I couldn’t see at the time.
That is why Fertility Block Mapping starts with a plain list: what was run, what came back, and what was never asked. Seeing your own gaps on one page is often the moment the next conversation with your doctor finally becomes specific.
