Recent thoughts on management and prevention of recurrent early pregnancy loss

To provide an overview of the latest views and evidence available to clinicians managing couples with recurrent early pregnancy loss (RPL).

RPL is a heterogeneous condition associated with many pathologies, none of which is found in more than 50% of couples after routine investigations. The recommended treatment of low-dose aspirin and heparin in women with antiphospholipid syndrome has a weak evidence base. Recent randomized controlled trials (RCTs) of low-dose aspirin and heparin have failed to find an improvement in live birth rates, even in the presence of thrombophilia. Although parental karyotypic abnormalities are associated with RPL, conservative management of such couples may be optimal. Observational studies of hysteroscopic metroplasty have promising results, but evidence from RCTs is awaited. Progestogen therapy may improve pregnancy outcomes, but further RCTs are needed. Immunological factors are thought to be important in idiopathic RPL. Research is focused on natural killer cells and cytokines in influencing implantation as potential therapeutic treatments. Currently, RCTs have not substantiated a benefit for immunotherapy.

Management of RPL remains challenging, with many controversial issues regarding the underlying pathophysiology. Improvements in live birth rates in subsequent pregnancies have not been found in RCTs of treatment for most of the associated conditions. All women can be offered supportive care in subsequent pregnancies. Empirical treatment is widely used in idiopathic RPL. A better option may be to encourage women to participate in high-quality and methodologically sound studies to guide optimal management.