This article is about pregnancy loss. If that is too close right now, it can wait. It will still be here when you want it.
This is education, alongside your medical care, never instead of it. Nothing here is a diagnosis, and nothing here can tell you why a particular loss happened. The guidelines below are what I would want you to know before your next appointment.
After one miscarriage, most doctors don't order tests, and that is in line with the guidelines. About half of early losses are caused by a chromosomal problem in that pregnancy, which no test of yours or your partner's would have found. After two losses, both the European guideline (ESHRE) and the American fertility society (ASRM) say a workup makes sense, but they don't list the same tests. In Germany, the national guideline starts at three losses, and after two in justified individual cases. So after two losses it is worth asking your doctor directly, and asking which guideline your clinic follows.
Why are tests usually not done after one miscarriage?
Because one loss is common and often caused by the pregnancy itself. The American College of Obstetricians and Gynecologists (ACOG) says no workup is generally recommended until after a second loss in a row.
ACOG puts early pregnancy loss at about 10% of clinically recognized pregnancies, and about 50% of these losses are due to chromosomal abnormalities in the pregnancy. Those are set at conception, which is why going back over that week so rarely finds an answer.
That is the reasoning behind "this is very common, try again when you feel ready". The sentence is medically accurate. It can still feel like nobody looked. If you had one loss and were told no tests are needed, that is standard advice, and it doesn't mean something was missed.
ACOG also notes that there are no quality data to support delaying another attempt after an early loss. When you try again is a decision for the two of you, based on how you both feel and on your doctor's advice about your own situation.
When does a doctor look further?
ESHRE and ASRM both count recurrent pregnancy loss from two losses. The German guideline still uses three, with exceptions after two, so what you are offered depends on where you live and on your doctor.
| Guideline | When a workup can start |
|---|---|
| ESHRE (Europe), 2022 | A diagnosis of recurrent pregnancy loss can be considered after two or more losses, consecutive or not |
| ASRM (USA), 2026 | Two or more losses, consecutive or not, starting with chromosome testing of the tissue from the second loss |
| ACOG (USA), 2018 | No workup generally recommended until after the second consecutive loss |
| AWMF (Germany), 2022 | Workup after three consecutive losses, and after two in justified individual cases |
If you have had two losses and nobody has raised the question, you can raise it. You don't need a referral from me or anyone else to ask whether a workup makes sense for you now, or what the reasons would be for waiting.
What does a workup after two losses usually include?
In Europe, ESHRE recommends thyroid tests (TSH and TPO antibodies), antiphospholipid antibodies and an assessment of the uterus. In the US, ASRM's 2026 opinion starts with chromosome testing of the pregnancy tissue and a look at the uterine cavity, and adds other tests depending on the result and your history.
Here is the European list, with how strongly ESHRE recommends each test.
| What is checked | Why | ESHRE 2022 |
|---|---|---|
| TSH and TPO antibodies | Thyroid function, and antibodies that can be raised while TSH is still in range | Recommended (strong) |
| Antiphospholipid antibodies | An autoimmune condition that affects blood clotting. Usually lupus anticoagulant and anticardiolipin antibodies, sometimes anti-beta2 glycoprotein I | Recommended after two losses (strong) |
| Shape of the uterus | Some differences in uterine shape are linked to loss. Transvaginal 3D ultrasound is the preferred method | Recommended for all (strong); method conditional |
| Chromosomes of both partners | A balanced rearrangement in either partner can be passed on unbalanced | After individual risk assessment (conditional) |
| Genetics of the pregnancy tissue | Can explain a particular loss | Not routine, can be done to explain a loss (conditional) |
How the American guidance differs
ASRM replaced its 2012 opinion in 2026. It recommends chromosome testing of the pregnancy tissue (array-based testing) and an evaluation of the uterine cavity for everyone with recurrent loss. If the tissue shows a chromosomal cause, that often explains the loss. Parental karyotypes, antiphospholipid antibodies and TSH are recommended in certain circumstances. One difference to know about: ASRM does not recommend testing for thyroid antibodies, while ESHRE does. If you are being looked after during a second loss right now, ask whether the tissue can be sent for chromosome testing. It can only be done at that time.
Your doctor will also ask about your medical and family history, including thyroid problems, PCOS, diabetes, clotting problems and irregular cycles. I wrote more about the thyroid antibody that is often left out in what a "normal" thyroid and progesterone can miss.
What usually isn't tested routinely
Here the two guidelines agree. Neither recommends routine testing for inherited clotting disorders (hereditary thrombophilia), natural killer (NK) cells or ovarian reserve, and both reserve prolactin testing for women with symptoms such as irregular or absent periods. The ESHRE patient guideline also lists HLA typing and luteal phase progesterone tests as not routinely recommended. If one of these is offered, it is fair to ask what the result would change.
ESHRE states that in the majority of couples with recurrent pregnancy loss, no cause is found. That is called unexplained recurrent pregnancy loss. It means the tests that exist today found nothing that explains the losses. It doesn't mean you or your partner did something wrong, and it doesn't mean your doctor stopped looking too early.
Where does your partner come in?
A loss happens to both of you. ESHRE recommends assessing the male partner's lifestyle, and both ESHRE and ASRM say sperm DNA fragmentation testing can be considered. If parental chromosome tests are done, they are done for both partners.
Most of the attention after a loss goes to her body. The guideline is clear that his health is part of the picture too. ESHRE's strong recommendation is to look at his lifestyle: smoking, alcohol, weight and exercise. Sperm DNA fragmentation testing is a conditional option to help explain losses. ASRM notes that a standard semen analysis does not appear to predict recurrent loss, and ESHRE notes that antioxidants have not been shown to improve outcomes.
Grief belongs to both of you as well. Partners often feel they have to hold things together and get asked less about how they are doing. If it is getting heavy for either of you, that deserves real support, from a counsellor or a support organisation. The ESHRE patient guideline names the Miscarriage Association (UK) as one example.
What should I ask my provider?
Ask whether, with your history, a workup makes sense now or later and why, which of the recommended tests have already been done, and whether your partner is part of the assessment.
- Ask about timing. "With my history, would you look into this now, or would you wait? What is the reason?"
- Go through what has been done. Thyroid (TSH, and TPO antibodies if your clinic follows ESHRE), antiphospholipid antibodies, an ultrasound of the uterus.
- Ask which guideline your clinic follows. European and American recommendations differ on some tests.
- Ask about the pregnancy tissue. "Was any chromosome testing done, and would it help in our case?" During a loss, this is the moment to ask.
- Include your partner. His lifestyle, and whether chromosome tests for both of you make sense.
- Ask about next time. "If I am pregnant again, what early care or scans would you suggest?"
You could say:
"We have had two losses. I have read that the European guideline suggests looking at thyroid antibodies, antiphospholipid antibodies and the uterus after two. Could we talk about whether that makes sense for us now, and whether my partner should be part of it?"