ESHRE guideline: recurrent pregnancy loss

Abstract

STUDY QUESTION What is the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 77 recommendations answering 18 key questions on investigations and treatments for RPL, and on how care should be organized. WHAT IS KNOWN ALREADY A previous guideline for the investigation and medical treatment of recurrent miscarriage was published in 2006 and is in need of an update. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 31 March 2017 and written in English were included. Cumulative live birth rate, live birth rate and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 38 recommendations on risk factors, prevention and investigations in couples with RPL, and 39 recommendations on treatments. These include 60 evidence-based recommendations – of which 31 were formulated as strong recommendations and 29 as conditional – and 17 good practice points. The evidence supporting investigations and treatment of couples with RPL is limited and of moderate quality. Of the evidence-based recommendations, only 10 (16.3%) were supported by moderate quality evidence. The remaining recommendations were supported by low (35 recommendations: 57.4%), or very low quality evidence (16 recommendations: 26.2%). There were no recommendations based on high quality evidence. Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions investigations and treatments that should not be used for couples with RPL. LIMITATIONS, REASONS FOR CAUTION Several investigations and treatments are offered to couples with RPL, but most of them are not well studied. For most of these investigations and treatments, a recommendation against the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in RPL, based on the best evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. One of the most important consequences of the limited evidence is the absence of evidence for a definition of RPL. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. J.E. reports position funding from CARE Fertility. S.L. reports position funding from SpermComet Ltd. S.M. reports research grants, consulting and speaker’s fees from GSK, BMS/Pfizer, Sanquin, Aspen, Bayer and Daiichi Sankyo. S.Q. reports speaker’s fees from Ferring. The other authors report no conflicts of interest. ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.

Comparison of therapeutic interventions for recurrent pregnancy loss in association with antiphospholipid syndrome: A systematic review and network meta‐analysis

“…Recurrent pregnancy loss (RPL) can be identified based on an obstetrical history which includes the loss of two or more pregnancies and is known to affect about 1%‐2% of women . However, some aspects of the definition of RPL such as the condition of being “consecutive” and the requisite number of miscarriages have been disputed (Table ) . Here, we adopted the definition from The European Society of Human Reproduction and Embryology (ESHRE 2018).…”

Comparison between thrombophilic gene polymorphisms among high risk patients

“…According to ESHRE guideline for RPL testing for hereditary thrombophilia is not suggested unless the women have other risk factors, such as family history of hereditary thrombophilia or previous venous thromboembolism (VTE) [16]. However, according to a research, conducted among 154 Bulgarian women with single embryonic loss and 100 healthy controls, it was concluded that F V Leiden had an impact on adverse pregnancy outcomes, especially in the second and third trimester [17].…”

The role of CXC chemokine ligand 16 in physiological and pathological pregnancies

“…Recurrent miscarriage (RM), also known as recurrent pregnancy loss, is defined as experiencing at least two or three consecutive fetal deaths or spontaneous abortions before the 24th gestational week . Although RM has complex causes, including chromosome abnormalities, anatomical defects, acquired infection, antiphospholipid syndrome, and endocrine disease, the cause of RM remains unexplained in almost half of patients .…”