For years, many women and couples including myself were told some version of:

“Miscarriage is common.”

“Try again.”

“We don’t usually do a full workup until after three losses.”

And while miscarriage is sadly common, that advice has never fully sat right with me.

Because when someone has experienced one pregnancy loss, it matters.

When someone has experienced two, it deserves attention.

And when the body is sending a repeated signal, the answer should not be to simply wait for more heartbreak before asking deeper questions.


Recently, the American Society for Reproductive Medicine updated its guidance on recurrent pregnancy loss, and the shift is important. ASRM now defines recurrent pregnancy loss as the spontaneous loss of two or more pregnancies, excluding confirmed molar or ectopic pregnancies. The updated guidance also recognizes that pregnancies confirmed by urine or blood HCG can count; ultrasound confirmation is not required. (see UPDATE) 

In plain English:

You do not necessarily need to wait for three miscarriages before seeking a more thorough evaluation.

And that matters.


Why This Update Matters

Pregnancy loss is often discussed as if it is random.

And sometimes, it is.

Many first-trimester miscarriages are related to chromosomal abnormalities in the embryo, especially as maternal age increases. That does not mean anyone caused it. It does not mean someone failed. It means early pregnancy is biologically complex.

But repeated loss deserves a different level of investigation.

Recurrent pregnancy loss is not simply “infertility.” ASRM describes it as a distinct condition that requires its own evaluation and management. That distinction matters because getting pregnant and staying pregnant are not always the same biological process. A person may be able to conceive, but the pregnancy may not be supported long enough to continue. That is where deeper evaluation looking at the root cause can be helpful.


What the Updated ASRM Guidance Emphasizes

The updated ASRM opinion supports a more stepwise approach to recurrent pregnancy loss evaluation.

One of the major shifts is the recommendation to begin, when possible, with chromosome evaluation of the miscarriage tissue itself.

Why?

Because understanding whether a loss was chromosomally normal or abnormal can change the next steps.

If a miscarriage was caused by a chromosomal abnormality, the pathway may look different than if the embryo was chromosomally normal and the loss may have been influenced by uterine, immune, endocrine, metabolic, male factor, or inflammatory patterns.

This is where the conversation becomes more nuanced.

The goal is not to run every test on every person.

The goal is to ask better questions.


What Can Be Looked At After Two Losses?

A recurrent pregnancy loss evaluation may include several categories, depending on history, risk factors, age, symptoms, and what testing has already been done.

These may include:

1. Chromosome testing of miscarriage tissue

When available, testing the pregnancy tissue can help determine whether the loss was related to chromosomal abnormalities.

This can provide important information and may help guide whether additional testing is needed.

2. Uterine cavity evaluation

Structural factors can influence implantation and pregnancy continuation.

This may include evaluation for things like uterine septum, fibroids, polyps, adhesions, or retained pregnancy tissue.

Common tools may include saline sonogram, hysterosalpingogram, or hysteroscopy.

3. Parental chromosome testing

In certain situations, parental karyotyping may be considered, especially if miscarriage tissue suggests an unbalanced chromosomal rearrangement or if miscarriage tissue was not available for testing.

4. Thyroid evaluation

Thyroid function plays an important role in fertility, pregnancy, and early fetal development.

In recurrent pregnancy loss, thyroid testing may be considered, especially when there are symptoms, risk factors, a euploid miscarriage, or no miscarriage tissue testing available.

5. Blood sugar and metabolic health

Metabolic health matters for reproductive health.

ASRM recommends considering hemoglobin A1c testing in patients with risk factors such as PMOS (formally PCOS), higher BMI, age over 40, family history of diabetes, or history of gestational diabetes.

From a functional fertility perspective, this is one of the areas I pay close attention to because insulin resistance, blood sugar instability, and metabolic inflammation can influence hormone signaling, ovulation quality, endometrial receptivity, and pregnancy health.

6. Antiphospholipid syndrome evaluation Antiphospholipid syndrome is an autoimmune clotting condition that can be associated with pregnancy loss.

Testing is not necessarily appropriate for every person after every miscarriage, but it may be indicated depending on clinical history and loss pattern.

This is one reason a thoughtful intake matters.

7. Chronic endometritis

Chronic endometritis is low-grade inflammation of the uterine lining and may be considered in some cases of otherwise unexplained recurrent pregnancy loss, especially when infertility is also present.

This is different from endometriosis.

It is often subtle and may not cause obvious symptoms.

8. Male factor beyond a standard semen analysis

This is one of the areas that is often overlooked.

A standard semen analysis looks at sperm count, motility, morphology, and volume.

But it does not fully assess sperm DNA integrity.

The updated ASRM guidance notes that sperm DNA fragmentation testing may be considered in otherwise unexplained recurrent miscarriage or when recurrent miscarriage occurs alongside infertility.

This is important because male factor is not only about whether sperm can fertilize an egg.

It is also about the quality of the genetic contribution and whether sperm DNA damage may influence embryo development, placental development and miscarriage risk.


Why “Everything Looks Normal” May Not Be Enough

Many women come to fertility care after being told:

“Your labs are normal.”

“Your partner’s semen analysis is normal.”

“Your uterus looks fine.”

“It may just be bad luck.”

Sometimes that is true.

But sometimes “normal” means the investigation was incomplete.

A conventional fertility workup often focuses on whether ovulation is happening, whether tubes are open, whether sperm meets basic parameters, and whether major structural issues are present.

Those are important. But they may not fully answer the question:


That question requires a broader lens.

It may involve hormones, thyroid function, insulin signaling, inflammation, nutrient status, oxidative stress, immune patterns, uterine environment, sperm DNA quality, and nervous system capacity.

This does not mean every miscarriage has a preventable cause.

It means repeated loss deserves more than reassurance alone.


The Emotional Cost of Waiting

There is also an emotional cost to telling someone to wait.

A miscarriage is not just a lab result or a clinical event.

It is a pregnancy.

A timeline.

A name someone may have imagined.

A due date.

A future that suddenly disappeared.

When someone experiences repeated loss, being told to “just try again” without a plan can feel dismissive and destabilizing.

ASRM’s updated guidance also emphasizes psychological support as an essential part of miscarriage care.

That matters.

Because people navigating recurrent loss need clinical evaluation, but they also need validation.

They need someone to say:

This matters.

You are not overreacting.

Your body is not failing you.

And we can start looking for answers.


What This Means for Patients

If you have had two pregnancy losses, it is reasonable to ask for a deeper evaluation.

That does not mean something is definitely wrong.

It means your history deserves to be taken seriously.

You can ask your clinician:

* Do I meet criteria for recurrent pregnancy loss evaluation?

* Should miscarriage tissue be tested if another loss occurs?

* Have we evaluated my uterine cavity?

* Has my thyroid been assessed from a fertility and pregnancy perspective?

* Should we look at metabolic markers like fasting insulin, glucose, and hemoglobin A1c?

* Are there signs that sperm DNA fragmentation testing may be appropriate?

* Are there inflammatory, immune, or uterine lining factors that should be considered?

* What has been ruled out, and what has not actually been evaluated yet?

The goal is not to create fear. The goal is to replace guessing with clarity.


A Functional Fertility Perspective

At Vital Fertility, I approach recurrent pregnancy loss through the lens of biological readiness.

That means looking beyond whether someone can get pregnant and asking whether the body has the hormonal, metabolic, inflammatory, nutritional, and reproductive support needed to sustain a healthy pregnancy.

This is not about blaming the body.

It is about listening to it.

Pregnancy requires coordination across multiple systems: ovarian function, thyroid signaling, blood sugar regulation, immune tolerance, uterine receptivity, nutrient sufficiency, sperm quality, and nervous system safety.

When losses repeat, I believe we owe patients a deeper look.

Not random supplements.

Not generic reassurance.

Not “come back after one more.”

A real investigation.


You Do Not Have to Wait for More Heartbreak

If you have experienced two miscarriages, you do not need to minimize what happened.

You do not need to wait until loss number three before asking for answers.

And you do not need to accept “everything looks normal” if the testing has only scratched the surface.

The updated ASRM guidance reflects what many patients have known in their bones for a long time:

Two losses are enough to deserve attention.

Two losses are enough to ask better questions.

Two losses are enough to start looking deeper.


At Vital Fertility, my work is focused on helping women and couples identify what may be disrupting fertility and pregnancy health, so their next decisions are grounded in biology, not guesswork.


If you are navigating recurrent pregnancy loss, unexplained infertility, or repeated disappointment after being told everything looks normal, a deeper evaluation may be the next right step.

You deserve answers before another cycle of uncertainty.