Recurrent Miscarriage After Embryo Transfer: Causes, Next Steps and When to Consider Surrogacy

Embryo Abnormalities

Embryo chromosome abnormalities are a leading cause of early pregnancy loss.

ASRM estimates that 50%–60% of first-trimester miscarriages are caused by embryonic aneuploidy, or an abnormal number of chromosomes.

What intended parents know about that risk depends partly on embryo testing:

The role of genetic embryo testing is to provide more information about chromosome status before transfer, not guarantee a healthy pregnancy.

A study examining chromosomal causes of miscarriage found that patients whose previous miscarriage had a chromosome abnormality had better subsequent pregnancy outcomes than those whose previous miscarriage was chromosomally normal.

The study involved natural pregnancies rather than IVF transfers, but its findings show why the chromosome status of a loss can help guide what doctors investigate next.

If testing identifies a chromosome abnormality, it may help explain why that pregnancy ended.

If miscarriages continue with euploid embryos or chromosomally normal pregnancy tissue, your fertility specialist may have more reason to investigate uterine, hormonal, autoimmune or other causes.

Uterine Abnormalities

Uterine abnormalities can contribute to recurrent miscarriage when the shape or condition of the uterine cavity interferes with a pregnancy after implantation.

Conditions your fertility specialist may evaluate include:

• A uterine septum
• Fibroids that affect the uterine cavity
• Endometrial polyps
• Intrauterine adhesions
• Adenomyosis
• Chronic endometritis

A review of uterine factors in miscarriage found associations between recurrent pregnancy loss and congenital uterine differences such as septate, bicornuate and unicornuate uteruses.

The review also discussed acquired abnormalities including intrauterine adhesions, polyps and submucosal fibroids.

Your fertility clinic may use a saline infusion sonogram to outline the uterine cavity with fluid during ultrasound. Hysteroscopy allows a physician to look directly inside the uterus and, in some cases, remove a polyp, divide adhesions or treat certain fibroids.

Adenomyosis and chronic endometritis may also be considered depending on symptoms, previous findings and treatment history.

Evidence is less settled for some of these conditions, so finding an abnormality does not automatically establish that it caused your miscarriages.

Before delaying another transfer for treatment or surgery, ask how strongly the finding is associated with your losses and whether treating it has evidence of improving live birth rates in patients with a similar history.

Hormonal and Endocrine Disorders

Hormonal and endocrine disorders can contribute to pregnancy loss when they interfere with the hormonal support or metabolic conditions needed to maintain pregnancy.

Thyroid disease, poorly controlled diabetes, prolactin disorders and metabolic conditions associated with PCOS may be considered depending on your symptoms and medical history.

Current recurrent miscarriage treatment guidance includes evaluation for endocrine problems when they are clinically relevant. ASRM also recommends treating overt thyroid disease and uncontrolled diabetes when present.

Luteal phase insufficiency is sometimes raised as a possible explanation for early miscarriage because progesterone supports the uterine lining and early pregnancy.

The evidence is less clear than the term may suggest, and luteal phase deficiency has not been proven to be an independent cause of recurrent pregnancy loss.

Progesterone still has an established role in many embryo-transfer protocols.

For recurrent miscarriage specifically, current guidance supports a more individualized approach rather than assuming that additional progesterone will benefit every patient.

If you’ve miscarried despite progesterone support, ask your fertility clinic to review the timing, route and dose used in previous transfers. The useful question is whether a different protocol addresses something identified in your case rather than simply adding more medication.

Blood Clotting and Autoimmune Conditions

Some blood clotting and autoimmune conditions can contribute to recurrent pregnancy loss, but the strength of the evidence depends on the specific condition.

Antiphospholipid syndrome has a well-established association with recurrent miscarriage, while routine testing for many other clotting and immune abnormalities is not recommended.

Antiphospholipid syndrome, or APS, is an autoimmune disorder in which antiphospholipid antibodies can contribute to inflammation and abnormal clotting processes that interfere with pregnancy.

Research on autoimmune recurrent pregnancy loss continues to examine these mechanisms.

APS testing generally includes:

• Lupus anticoagulant
• Anticardiolipin antibodies
• Anti-beta-2-glycoprotein I antibodies

Diagnosis requires specific clinical and laboratory criteria rather than a single abnormal test.

Inherited thrombophilias such as Factor V Leiden and prothrombin gene mutations are different.

ASRM does not recommend routine inherited thrombophilia testing for recurrent pregnancy loss because current evidence has not shown that universal testing and anticoagulation improve live birth rates.

Lupus and other diagnosed autoimmune disorders may require specialist management, but broad immune panels are another matter.

Routine natural killer cell testing and other immune testing remain controversial and are not part of the standard recurrent pregnancy loss workup.

If an immune test or treatment is being proposed, ask what diagnosed condition it is intended to identify or treat and whether treating a positive result has been shown to improve live birth rates.

Male Factor and Sperm DNA Fragmentation

Male-factor infertility may contribute to recurrent miscarriage in some cases, particularly when sperm DNA damage is present.

The evidence is still developing, so sperm DNA fragmentation testing is generally considered selectively rather than ordered for every couple experiencing pregnancy loss.

A review of male factors in miscarriage found evidence linking elevated sperm DNA fragmentation with unexplained recurrent pregnancy loss while also noting important limitations in the available research.

Factors associated with sperm DNA damage may include:

• Oxidative stress
• Smoking
• Environmental exposures
• Varicocele
• Paternal age
• Other male reproductive health conditions

ASRM’s 2026 guidance states that sperm DNA fragmentation testing may be considered when recurrent pregnancy loss occurs alongside infertility.

Standard semen parameters alone do not appear to predict recurrent pregnancy loss reliably.

If embryo or pregnancy testing has not explained the losses and male-factor infertility is already part of your treatment history, ask whether evaluation by a reproductive urologist could identify something that would change your IVF plan.

The Emotional Impact of Repeated Pregnancy Loss During IVF

Repeated pregnancy loss during IVF can make each treatment decision harder because a positive pregnancy test no longer answers the question you most need answered: whether the pregnancy will continue.

The physical demands of treatment can also accumulate alongside grief, financial pressure and uncertainty about whether another transfer will produce a different result.

Partners may not reach the same conclusion at the same time.

One person may want another transfer quickly while the other wants additional testing, a treatment break or information about another family-building option.

Practical forms of support can include counseling with a professional experienced in infertility and pregnancy loss, pregnancy-loss or infertility support groups and conversations with your fertility team about whether a treatment break would affect the medical plan.

Resources on coping after failed IVF can also help you separate the emotional impact of previous treatment from the medical question of what should happen next.

Before another transfer, consider asking your fertility clinic what it believes caused the previous losses, what would change in the next cycle and what evidence suggests that change could improve your chance of live birth.

What Testing Is Recommended After Recurrent Miscarriage Following IVF?

Testing after recurrent miscarriage following IVF should look for factors that could explain why pregnancies are ending after implantation.

The workup usually focuses on embryo or pregnancy genetics, uterine anatomy, selected hormonal conditions, antiphospholipid syndrome and, in some cases, male-factor concerns.

ASRM defines recurrent pregnancy loss as two or more spontaneous pregnancy losses and recommends a stepwise evaluation.

A detailed recurrent miscarriage diagnostic workup may include several categories of testing depending on what has already been evaluated.

Possible testing includes:

• Pregnancy-tissue chromosome testing: This can identify whether a miscarriage involved a chromosome abnormality and help determine what testing should follow.
• Uterine cavity evaluation: Ultrasound, saline sonography, HSG or hysteroscopy can identify structural abnormalities, retained pregnancy tissue or adhesions.
• Genetic evaluation: Parental karyotyping may be appropriate when miscarriage testing identifies a structural chromosome abnormality or family history raises concern for a chromosome rearrangement.
• Hormonal and metabolic testing: Thyroid testing is commonly considered. HbA1c or prolactin testing may be appropriate when symptoms or risk factors support it.
• APS testing: Blood tests can identify the antiphospholipid antibodies used when diagnosing antiphospholipid syndrome.
• Targeted male-factor testing: Sperm DNA fragmentation testing or reproductive urology evaluation may be considered when recurrent pregnancy loss occurs alongside infertility.

Each category answers a different question.

Pregnancy-tissue testing looks for an explanation within the pregnancy itself, uterine imaging looks for conditions that may interfere with carrying a pregnancy and blood testing looks for specific medical conditions that may be treated or managed.

Knowing what is not routinely recommended can also save time and money.

ASRM does not recommend universal inherited thrombophilia screening, natural killer cell testing, endometrial receptivity testing or microbiome testing as part of the standard workup for recurrent pregnancy loss after IVF.

Before agreeing to another test, ask what diagnosis your doctor is investigating and how a positive or negative result would change the treatment plan.

Possible IVF Protocol Adjustments After Recurrent Miscarriage

IVF protocol changes after recurrent miscarriage should be based on what the evaluation finds rather than applied automatically.

There is no single medication, transfer protocol or add-on treatment that ASRM recommends for everyone with repeated pregnancy loss.

Depending on your findings, your fertility clinic may discuss:

The ASRM recurrent loss recommendations caution against assuming that additional treatment improves unexplained recurrent pregnancy loss.

PGT-A may be considered in selected circumstances, but it has not been shown overall to improve live birth rates or significantly reduce miscarriage for all patients with recurrent pregnancy loss.

Routine treatment with low-dose aspirin, enoxaparin, glucocorticoids, heparin, endometrial scratching, G-CSF, intralipid therapy, IVIG and several other empiric interventions has not demonstrated a consistent benefit for unexplained recurrent pregnancy loss.

Progesterone has more circumstance-specific guidance rather than serving as a universal solution.

Continued treatment can still be reasonable.

ASRM reports that 50%–80% of patients with unexplained recurrent pregnancy loss ultimately succeed in a subsequent pregnancy attempt without a specific intervention, but that range is not a personal IVF success rate.

If your doctor can identify something another transfer would meaningfully change, continued IVF may still make sense.

If suitable embryos are implanting but carrying the pregnancy appears to be the unresolved problem, that is when gestational surrogacy deserves a separate comparison.