Clinical management of recurrent pregnancy loss: a critical assessment of international guidelines.

OBJECTIVE

To compare the methodological quality, evidence-grading systems, and clinical recommendations of the guidelines for recurrent pregnancy loss (RPL).

METHODS

This narrative review evaluated the European Society of Human Reproduction and Embryology (ESHRE), Royal College of Obstetricians and Gynaecologists (RCOG), Australasian Clinical Practice Guideline for Recurrent Pregnancy Loss (ACCEPT), and American Society for Reproductive Medicine (ASRM) guidelines. Methodological quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An overall recommendation grade (A, B, or C) was assigned using a previously published complementary classification system. Evidence-grading systems, recommendation strength, and clinical recommendations were compared across the major etiological domains of RPL.

RESULTS

ESHRE and RCOG demonstrated the highest methodological quality and were classified as Grade A, whereas ACCEPT and ASRM were classified as Grade B. Heterogeneity was observed in evidence-grading systems and recommendation frameworks. ESHRE, RCOG, and ACCEPT adopted different approaches to evaluating evidence, whereas ASRM did not use a formal evidence-grading system.The guidelines differed substantially in their definitions of RPL and recommendations regarding genetic evaluation, uterine surgery, endocrine disorders, inherited thrombophilias, reproductive immunology, chronic endometritis, and unexplained RPL. Broad consensus was observed regarding antiphospholipid syndrome, uterine cavity assessment, thyroid dysfunction, lifestyle modification, and psychological support.

CONCLUSIONS

RPL guidelines exhibit important methodological and clinical heterogeneity that extends beyond differences in the available evidence. Harmonization of diagnostic definitions, standardized approaches to evidence appraisal, greater transparency in consensus development, and high-quality randomized controlled trials are needed to improve and facilitate precision medicine in RPL.