What Is Recurrent Pregnancy Loss (RPL)?
Recurrent pregnancy loss (RPL) is defined as 2 or more pregnancy losses before 20 weeks gestation. It affects approximately 1–2% of couples trying to conceive.
Each individual miscarriage is usually chromosomally driven (random error). But when losses repeat, a systematic cause should be investigated.
Common Causes of RPL
| Category | Cause | Frequency |
|---|---|---|
| Chromosomal | Embryo aneuploidy (random or parental translocation) | 50–60% of all miscarriages |
| Anatomical | Uterine septum, fibroids, polyps, adhesions | 10–15% |
| Thrombophilic | Antiphospholipid syndrome (APS), inherited clotting disorders | 10–15% |
| Hormonal | Thyroid dysfunction, elevated prolactin, luteal phase defect | 10–15% |
| Immunological | NK cell dysregulation, alloimmune factors | Under investigation |
| Male factor | Sperm DNA fragmentation | 5–10% |
| Unexplained | No identifiable cause | 30–50% |
RPL Diagnostic Workup at Korean Clinics
A thorough RPL investigation typically includes:
Blood Tests
- Antiphospholipid antibodies: Anticardiolipin IgG/IgM, anti-β2-glycoprotein I, lupus anticoagulant
- Thyroid panel: TSH, Free T4, anti-TPO antibodies
- Prolactin level
- AMH, FSH, E2: Ovarian reserve assessment
- CBC, coagulation panel
- Karyotype (chromosomes): Both partners if parental translocation suspected
- Sperm DNA fragmentation index (DFI): For male partner
Uterine Assessment
- 3D pelvic ultrasound: Detects uterine anomalies (septum, fibroids)
- Hysteroscopy: Gold standard for intrauterine evaluation
- MRI: For complex anatomical assessment
Treatment by Cause
1. Chromosomal — PGT-A with IVF
For couples with RPL due to embryo chromosomal abnormalities (most common cause):
- IVF + PGT-A tests embryos before transfer
- Only chromosomally normal (euploid) embryos are transferred
- Reduces miscarriage rate by 50–70% in RPL patients
- Particularly effective for women over 35
2. Antiphospholipid Syndrome (APS)
Most treatable cause of RPL:
- Low-dose aspirin (75–100mg/day from positive test)
- Low molecular weight heparin (LMWH) injections from positive test through delivery
- Live birth rates improve from ~30% to 70–75% with treatment
3. Uterine Abnormalities
- Uterine septum: Hysteroscopic resection — most effective surgical intervention for RPL (improves live birth rate significantly)
- Fibroids: Myomectomy only if submucosal fibroids distorting the cavity
- Intrauterine adhesions: Hysteroscopic lysis
4. Thyroid Dysfunction
- TSH target: 1.0–2.5 mIU/L before conception and in 1st trimester
- Subclinical hypothyroidism: Treat if TSH > 2.5 in RPL patients
- Anti-TPO antibodies positive even with normal TSH: Consider low-dose thyroxine
5. Sperm DNA Fragmentation
If DFI > 25%:
- Antioxidant therapy for 3+ months (CoQ10, Vitamin C/E, lycopene)
- Lifestyle changes (no heat exposure, quit smoking, reduce alcohol)
- PICSI or MACS for sperm selection in IVF
- Testicular sperm extraction (TESE) — testicular sperm has lower fragmentation
6. Unexplained RPL
For couples with no identifiable cause, emerging treatments include:
- Progesterone supplementation from positive pregnancy test (PRISM trial evidence)
- Low-dose aspirin (some evidence)
- Immunotherapy (intralipid infusion, G-CSF uterine infusion) — still experimental; offered at some Korean centers
- Psychological support — evidence shows supportive care alone improves outcomes
RPL Investigation and IVF in Korea
Why Korea for RPL?
- Comprehensive RPL panels available at major clinics
- PGT-A widely available and well-priced compared to USA/UK
- Hysteroscopy available same-day or next-day in most clinics
- Immunological workup and treatment increasingly available
Cost of RPL Workup in Korea
| Investigation | Estimated Cost (KRW) | Approx. USD |
|---|---|---|
| Full RPL blood panel | 300,000–600,000 | $225–$450 |
| 3D ultrasound | 100,000–200,000 | $75–$150 |
| Hysteroscopy (diagnostic) | 200,000–400,000 | $150–$300 |
| Karyotype (couple) | 200,000–400,000 | $150–$300 |
| Sperm DFI test | 100,000–200,000 | $75–$150 |
| Total workup | 900,000–1,800,000 | $675–$1,350 |
After a Miscarriage: When to Try Again
| Situation | Korean Guideline |
|---|---|
| Natural miscarriage (no D&C) | After 1 normal menstrual cycle |
| After D&C | After 1–2 normal cycles |
| After RPL treatment started | Once treatment (aspirin/heparin/thyroid) is established |
| After hysteroscopy for septum | After uterine healing confirmed (~1–2 months) |
FAQ
Q. I've had 2 miscarriages. Should I investigate now or try again first?
International guidelines vary (some say investigate after 2, others after 3). If you've had 2 losses and are over 35, most Korean specialists recommend starting the workup now rather than waiting for a third loss.
Q. Can PGT-A prevent all miscarriages?
PGT-A significantly reduces chromosomal miscarriages (the most common type) but cannot prevent all losses. Anatomical, immunological, and other causes require separate evaluation.
Q. Is unexplained RPL hopeless?
No. About 65–70% of couples with unexplained RPL eventually have a successful pregnancy, even without a specific treatment. Careful monitoring, emotional support, and progesterone supplementation help most couples succeed.
📧 For hospital consultation and referral inquiries, contact: info@bronis.co.kr
Medical Disclaimer: RPL investigation requires specialist evaluation. This guide is for informational purposes only.