Recurrent Pregnancy Loss (RPL) Panel Discussion

Recurrent Pregnancy Loss (RPL) is a devastating condition, where two or more miscarriage occurs. It's a devastating condition. There is controversy about types of investigations and treatment which can be done in a case of RPL.
Feeling honoured to have moderated a panel discussion on "RPL" in “CREATE in ART 2025” to pay homage and commemorate the birth anniversary of Late Prof. B. N. Chakravarty through a whole day Scientific Session on “Current Thoughts in practicing Reproductive Medicine and Assisted Reproductive Technologies” on 2 August 2025.

1. RPL

2. “covers the care provided by secondary and tertiary healthcare professionals”

3. Case 1 27 yr old lady, conceived twice previously, no H/O subfertility 1 st pregnancy: 2 years ago, no fetal cardiac activity detected, D/C done 2 nd pregnancy: 1 year ago, initial β - hCG 394 mU /ml, dropped to 12 mU /ml after 3 days, conservative management Ques 1: Is it a case of RPL?

4. Chance of APS, other etiology same between 2 and 3 losses (van den Boogaard et al., 2013) From the time of conception until 24 weeks of gestation (RCOG, 2011) Includes- nonvisualized pregnancy losses biochemical losses resolved and treated PUL ultrasound done after complete expulsion of embryo Excludes ectopic and molar pregnancy Consecutive vs non-consecutive- same etiology, same prognosis (van den Boogaard et al., 2013; van den Boogaard et al., 2010; Youssef et al., 2020; Egerup et al., 2016) Avoid using- Spontaneous abortion, Chemical pregnancy, Blighted ovum

5. Ques 2: How would you investigate? Medical and family history?

6. Lifestyle factors of both the partners Medical history- thrombophilia , PCOS, and diabetes, Family history- hereditary thrombophilia . Longer time to pregnancy (TTP ) ( Arge et al., 2022).

7. Good practice point Age Lowest risk- 20-35 yr Risk rapidly increases after 40 yr Stress Cause vs effect BMI Very high or low- poor obstetric outcome Obesity- lowers live birth Impact of weight loss? Optimum BMI is recommended Smoking Poor obstetric outcome Impact of quitting? Cessation of smoking is recommended Alcohol Poor fetal outcome Impact of limiting alcohol? Limiting alcohol is recommended

8. Ques 3: Investigations suggested? APLA Thyroid Structural anomalies Genetic anomalies Male testing TORCH testing?

9. Ques 3:Genetic testing? Parents? Baby? If abnormal- what to do?

10. Screening for genetic factors Test Recommendation Association Contributing factor Prognosis Treatment Genetic analysis of pregnancy tissue Not routinely recommended Can be done for explanatory purpose By a-CGH Yes Yes No No Parental karyotype After individual risk assessment previous child with congenital abnormalities/ unbalanced chromosome abnormalities translocation in the pregnancy tissue Yes Yes Yes PGT Adoption Gamete donation Prenatal invasive test

11. Treatment of RPL with genetic background Recommendation All couples with results of an abnormal fetal or parental karyotype should receive genetic counselling . Inform about the possible treatment options PGT Natural conception with prenatal testing Gamete donation Adoption Rationale Very low quality of evidence PGT-SR could reduce the miscarriage rate but will not improve live birth rate or time to pregnancy ( Brezina et al., 2016). Needs good-quality RCT with modern technology and methodology

12. Ques 4: Thrombophilia testing? APLA- which tests? Hereditary thrombophilia testing? Treatment- before or after pregnancy?

13. Thrombophilia screening Test Recommendation Association Contributing factor Prognosis Treatment Hereditary thrombo-philia Not recommended except Research setting Additional risk factors (personal/ family) for thrombophilia FVL mutation Prothrombin mutation MTFHR mutation Protein C deficiency Protein S deficiency Antithrombin III deficiency No/ weak Unclear yes No Acquired thrombo-philia (APS) Postpone until 6 weeks after pregnancy loss Repeat test after 12 wk Lupus anticoagulant (LA) Anti- cardiolipin antibody ( IgG , IgM ) Yes Yes Yes Weak evidence (2 vs 3 loss) Anti- β 2 glycoprotein (a β 2GPI) Possible (not statistically significant) Possible No data No data

14. Treatment of RPL with Thrombophilia Recommendation Rationale Hereditary thrombophilia Antithrombotic ONLY Research setting VTE prophylaxis Systematic review- no benefit of LMWH for prevention of pregnancy loss in hereditary thrombophilia ( Skeith et al., 2016). Acquired thrombophilia (APS) Women who fulfil the laboratory criteria of APS and ≥3 pregnancy losses- Low-dose aspirin (75 to 100 mg/day) starting before conception prophylactic dose heparin (UFH, LMWH) after positive pregnancy test Combination of heparin and aspirin improves LBR in women with APS and RPL to 80% (≥3 PLs, no evidence for 2PLs) ( Hamulyák , et al., 2020; Middeldorp , 2014). Continue until delivery

15. Ques 5: Anatomical disorders? Test modality? Surgical correction?

16. Screening for anatomical disorders Test Recommendation Association Contributing factor Prognosis Treatment Congenital uterine malformations Uterine cavity assessment in all women 3D US- high sensitivity and specificity to d/d between septate and bicorporeal uterus Sonohysterography (SHG)- more accurate than HSG MRI- if 3D US not available Renal tract assessment if Mullerian anomaly is diagnosed Yes Some malformation No studies Surgical trial in septate uterus Acquired uterine malformations All women should have 2D US to rule out adenomyosis Yes Unclear No studies Unclear

17. Screening for anatomical disorders Cervical weakness- diagnosis based on a history of second-trimester miscarriage preceded by PPROM or painless cervical dilatation. No objective test in the non-pregnant state.

18. Treatment of RPL with uterine abnormalities Recommendation Congenital disorders Septate uterus Septum resection- No benefit based on international, multicentre, open label, RCT ( Rikken , et al., 2021) Bicorporeal uterus with normal cervix (former AFS bicornuate uterus) Metroplasty - Not recommended Hemi-uterus (former AFS unicornuate uterus) Uterine reconstruction- Not recommended Bicorporeal uterus and double cervix (former AFS didelphic uterus) Insufficient evidence Acquired disorders Submucosal fibroid Endometrial polyp Hysteroscopic removal- insufficient evidence Intramural fibroid Myomectomy - Not recommended Fibroid distorting uterine cavity Myomectomy - Insufficient evidence Intrauterine adhesion Hysteroscopic removal- Insufficient evidence

19. Treatment of RPL with uterine abnormalities Recommendation H/O second-trimester losses s/o cervical weakness serial cervical sonographic surveillance . Cervical insufficiency Singleton pregnancy + H/O second-trimester recurrent loss attributable to cervical weakness, a cerclage could be considered . No evidence that this treatment increases perinatal survival. Actual groups that benefit of cerclage include ≥3 prior adverse events Short cervix (<25 mm) + prior preterm birth (Story and Shennan , 2014). Possible harms associated with any surgery The GDG is cautious in the recommendations on cerclage for RPL, but strong in recommending ultrasound surveillance.

20. Ques 6: Metabolic and endocrine screening? Routine thyroid testing? Which tests for thyroid? Treatment for subclinical hypothyroidism? Any other tests- LPD, Homocysteine ? Treatment for other disorders?

21. Metabolic and endocrine screening Thyroid screening (TSH and TPO-antibodies) is recommended in women with RPL Abnormal TSH levels should be followed up by T4 testing Thyroid screening

22. Metabolic and endocrine screening Test Association Contributing factor Prognosis Treatment PCOS Yes Yes No Metformin in sporadic PL No studies in RPL Insulin resistance Yes No studies No studies No studies Fasting Insulin Inconsistent Unclear No studies No studies Fasting glucose No No No studies No studies Androgen (testosterone) Inconsistent No studies No studies No studies Free androgen index No studies No studies Possible No studies Elevated serum LH Inconsistent No studies Inconsistent No studies Prolactin Inconsistent No studies Possible Yes (Dopamine agonist) Ovarian reserve Unclear Unclear Low live-birth No studies Luteal phase insufficiency testing (Endometrial biopsy, midluteal progesterone) Inconsistent No studies No Possible (Progesterone, hCG ) Homocysteine Inconsistent Possible in PCOS No studies High dose folate , Vit B6 Aspirin+ LMWH Vitamin D Possible Possible No studies Vitamin D supplementation Tests NOT recommended

23. Treatment of RPL with metabolic and endocrine abnormalities Recommendation Rationale Overt hypothyroidism before conception or during early gestation treat with levothyroxine Benefit overweighs risks Subclinical hypothyroidism (SCH) Treatment may reduce the risk of miscarriage Balance potential benefit of treatment against the risks. Once pregnant, recheck TSH by 7-9 weeks conflicting evidence Thyroid disorders Thyroid autoimmunity Euthyroid - do not treat Once pregnant, recheck TSH by 7-9 weeks TABLET trial and T4life trial → L-T4 treatment does not increase the chance of a live birth in RPL and thyroid autoimmunity ( Dhillon -Smith, et al., 2019, van Dijk , et al., 2022)

24. Other endocrine disorders Luteal phase insufficiency Progesterone- insufficient evidence to improve live birth hCG - insufficient evidence to improve live birth Ovulation induction in PCOS Evidence too limited Glucose metabolism defects Metformin - insufficient evidence to prevent pregnancy loss Vitamin D Preconception care – consider supplemental vitamin D (ACOG Committee Opinion No. 495: 2011, Del Valle et al., 2011). Treatment of RPL with metabolic and endocrine abnormalities

25. Ques 7: Any testing for male partner? Routine semen analysis? Any other tests? Remedy of abnormal test?

26. Male Factor Test Recommendation Association Contributing factor Prognosis Treatment Sperm DNA fragmentation (SDF) Consider for diagnostic purpose Correct assay of SDF? Yes Yes Needs further studies Lifestyle changes ICSI using hyaluronan (PICSI) Assess lifestyle factors in the male partner Age Smoking Alcohol Exercise BMI SDF is associated with advanced paternal age, unhealthy lifestyles (smoking, obesity and excessive exercise) (de Ligny , et al., 2022, Sharma et al., 2013, Wright et al., 2014).

27. Lifestyle changes Cessation of smoking Normal body weight Limited alcohol consumption Normal exercise pattern Physiological intracytoplasmic sperm injection (PICSI) No evidence to support Antioxidants Does not increase livebirth rate Treatment of RPL with Male factor

28. Ques 8: Immunological testing? To test or not? What tests? Treatment for abnormal tests?

29. Immunological screening Test Recommendation Association Contributing factor Prognosis Treatment Anti-nuclear antibodies (ANA) Could be considered for explanatory purpose Possible Possibly no Unclear Not available Human Leukocyte Antigen (HLA) Not recommended in clinical practice. Only Maternal HLA class II determination (HLA-DRB1*15:01, HLA-DRB1*07 and HLADQB1*05:01/05:2) could be considered in Scandinavian women with secondary RPL after the birth of a boy, for prognostic purposes. Strong Yes Negative impact on future live birth Not available Tests could be considered

30. Immunological screening Test Association Contributing factor Prognosis Treatment HLA compatibility Controversial No No Not available HLA-G Significant but weak No data No data Not available KIR and HLC-C Significant but weak No data No data Not available Cytokines Yes Unclear Unknown Not available Polymorphism in cytokine genes No association No No Not available Anti-HY immunity Moderate (Only Scandinavian) Yes (after birth of baby boy) Negative impact on live-birth Not available NK cell number in peripheral blood Weak Unclear Unclear Not available NK cell cytotoxicity in peripheral blood Unclear No No Not available NK cell in uterus/ endometrium Weak Unclear No Not available Anti sperm antibody No good quality evidence Anti HLA antibody Celiac disease antibody Tests NOT recommended

31. Case 2 34 years old, P0+5, all early miscarriages (6-8 weeks) All investigations normal Ques 9: What next?

32. Assessing prognosis of RPL Base prognosis on woman’s age her complete pregnancy history, including number of previous pregnancy losses, live births and their sequence. Prognostic tools ( Kolte & Westergaard ) can be used ( Kolte AM, Westergaard D, Lidegaard Ø, Brunak S, Nielsen HS. Chance of live birth: a nationwide,registry -based cohort study. Human reproduction (Oxford, England) 2021;36: 1065-1073.

33. Treatment of unexplained RPL Recommendation Rationale Vaginal Progesterone May improve live birth rate in women with ≥3 pregnancy losses and vaginal bleeding BD 400 mg from < 12 weeks to 16 weeks A meta-analysis and a Cochrane review → benefit of progestogen on miscarriage rate and live birth rate (Haas, et al., 2019, Saccone , et al., 2017). O ral dydrogesterone after fetal heart action is seen, may be effective. High doses of Intravenous immunoglobulin ( IvIg ) May improve live birth rate in women with ≥4 unexplained RPL 400 mg/kg for 5 consecutive days very early in pregnancy High-quality RCT→ IvIG given in to women with ≥4 unexplained RPL increased the LBR significantly (OR 2.60; 95%CI 1.15-5.86) ( Yamada et al., 2022).

34. Lymphocyte immunization therapy (LIT) Should not be used No significant effect May be serious adverse effects Glucocorticoids Not recommended Unexplained RPL RPL with selected immunological biomarkers. Intralipid Insufficient evidence G-CSF No evidence Heparin ± Low dose aspirin Not recommended Does not improve livebirth IVF+ PGT Insufficient evidence Endometrial scratch No evidence to recommend Low dose folic acid For prevention of NTD Not for RPL Treatment of unexplained RPL Not recommended

35. Psychological impact of RPL TLC- Only limited evidence- itself improves pregnancy outcome (Clifford et al., 1997, Liddell et al., 1997, Stray-Pedersen and Stray-Pedersen, 1984) Even if not, it is hard to argue against this approach.

36. IVF+ PGT (A) Chinese herbal treatment Acuouncture Homeopathy Antioxidants Non-conventional treatment for RPL

37. List of investigations

38. Summary of treatment

39. Grey areas APS diagnosed after 2 pregnancy loss ANA positive or HLA-II (DR, DQ) SCH, anti-TPO positive- conflicts with ATA guideline Surgical correction of uterine defects Cerclage - when, how Hyperhomocysteinaemia Unexplained RPL- progesterone and IVIG

40. Concluding remarks?

41. Thank you