Investigation protocol for recurrent pregnancy loss

The patient with recurrent pregnancy loss (RPL) usually seeks a diagnosis of the cause, a prognosis for further pregnancies, and treatment if available. The purpose of an investigation protocol is to assist physicians as to which investigations are worthwhile in order to reach a diagnosis. Various protocols have been published by leading professional organizations such as the Royal College of Obstetricians,1 the American College of Obstetricians and Gynecologists,2 the European Society of Human Reproduction and Embryology (ESHRE),3 and numerous others. However, virtually all protocols tend to classify RPL as one homogeneous condition, and try to suggest a group of investigations or treatment either based on an evidence-based approach or the experience of the particular authors. However, treating RPL as one homogeneous condition takes no account of indIVIdual circumstances in different patients. The prognosis is different in different patients. We classify patients into those with a good prognosis and those with a poor prognosis. We have tended to use an approach that differentiates between patients with a good or poor prognosis: primary versus secondary aborters,4 those with late versus early pregnancy losses (as late losses have a worse prognosis5), and recently those losing karyotypically abnormal versus those losing karyotypically normal embryos (as euploid abortions are associated with a worse prognosis than aneuploid abortions6). Additionally, treatment is often controversial, as demonstrated by the various debates in this book. We are of the opinion that there may not be one approach to treatment. For example, in antiphospholipid syndrome (APS), low-molecular-weight heparins (LMWH) and aspirin may be the standard treatment, but a different approach is indicated in the patient who continues losing pregnancies despite treatment. In this chapter, some of the standard protocols will be discussed, and some other approaches discussed that may be appropriate in particular patients.