Where I look deeper when you’re trying to get pregnant and stay pregnant.

Pregnancy loss is one of those areas of fertility care that I have A LOT of thoughts on — and honestly, one of the places where I see SO much room for additional support in our women’s health space. There is the loss itself, which is significant. There is the experience of becoming pregnant, beginning to imagine a baby and a future, and then having that pregnancy end. And then there is the question of: What do we actually DO with that information before trying again?

One of the biggest pieces I think we are still missing is connecting what we know about recurrent pregnancy loss with a much bigger conversation around availability to receive AND sustain a pregnancy. Because getting pregnant is only one part of fertility. We also need the physiology to support staying pregnant.

Today I want to share what I see being overlooked in the TTC with recurrent loss picture in my practice — and what I’ve seen help my clients get pregnant and stay pregnant when the paths they had already been given weren’t getting them where they wanted to go. But FIRST, I want to give you some context for where the current medical conversation around recurrent pregnancy loss actually stands.

Current RPL Standards of Care

Earlier this summer, the American Society for Reproductive Medicine (ASRM) updated its recurrent pregnancy loss guidelines for the first time in more than a decade.

RPL is now officially defined as two or more pregnancy losses before 22 weeks. They do NOT need to be consecutive, and this now includes biochemical pregnancies confirmed through blood or urine hCG, as well as clinical pregnancies. Ectopic and molar pregnancies are excluded.

Another important shift is where the investigation starts. When pregnancy tissue is available, chromosomal analysis of that tissue using array-based testing is now recommended as the first step.

From there, additional evaluation becomes more targeted based on those results and the individual history.

1. Genetic and chromosomal factors

• Chromosomal analysis of miscarriage tissue is now recommended as the first step when tissue is available.
• Parental karyotypes can be considered to look for things like a balanced translocation, depending on the results and individual history.
• Genetic counseling and, in certain cases, IVF with embryo testing can enter the conversation.

2. Clotting and autoimmune factors

• Testing for antiphospholipid syndrome (APS) — an acquired autoimmune clotting disorder associated with pregnancy loss.
• Diagnosis requires specific clinical criteria along with positive antibody testing on two separate occasions at least 12 weeks apart.
• Clinical history can include certain patterns of pregnancy loss, a previous blood clot, unexplained fetal loss after 10 weeks, or delivery before 34 weeks related to severe preeclampsia or placental insufficiency.
• When APS is diagnosed, treatment can include low-dose aspirin and injectable heparin.
• Inherited thrombophilias such as Factor V Leiden are not routinely screened for without additional clinical indication or relevant personal or family clotting history.

3. Hormone and metabolic factors

• TSH : Thyroid dysfunction is evaluated because of its relationship with pregnancy loss. A TSH above 2.5 mIU/L has historically raised concern in fertility and pregnancy care, although only TSH is being evaluated often at this stage and current guidelines do not use 2.5 as a universal treatment cutoff nor exploration of why the thyroid is sluggish.
• HbA1c / diabetes: Uncontrolled diabetes is associated with increased pregnancy-loss risk, with HbA1c typically only evaluated when diabetes risk factors are present.
• Blood sugar and insulin: These can be further evaluated (but aren’t always) when PCOS, insulin resistance or metabolic dysfunction is suspected, with metformin sometimes entering the treatment conversation. Drivers of this piece are often not fully examined.
• Prolactin: Elevated prolactin can interfere with ovulation and luteal function, so prolactin can be evaluated when the history suggests hyperprolactinemia or ovulatory dysfunction.
• Progesterone / luteal support: Post ovulatory progesterone support can enter the conversation in certain recurrent-loss situation, but drivers of this piece are often not fully examined.

4. Physical and anatomical factors

• Evaluation of the uterine cavity through a saline sonogram, HSG and/or hysteroscopy.
• Looking for things like a uterine septum, cavity-distorting fibroids, polyps, adhesions or other structural abnormalities.
• Surgical correction can be considered when an anatomical finding is believed to interfere with pregnancy.
• Chronic endometritis can also enter the evaluation in certain unexplained cases, with endometrial biopsy used for diagnosis and antibiotic treatment when appropriate.

And this is where I see the limitations.

I think ALL of this matters. I want these pieces appropriately investigated. I want to know if there was a chromosomal reason a pregnancy ended, if something is physically interfering with the uterine environment, or if uncontrolled diabetes, thyroid disease, APS or another identifiable medical factor needs to be treated.

But identifying an abnormal marker and treating that marker isn’t necessarily the same thing as understanding why that physiology is happening in the first place.

Take blood sugar and insulin. If these are elevated, medication like metformin can absolutely have a place. But I also want to know: Is this part of a bigger inflammatory or stress-based picture? Are we actually addressing the diet and lifestyle factors contributing to the metabolic dysfunction? What is happening with nutrition, movement, muscle, sleep, stress physiology and inflammation that could be keeping this pattern going?

The same goes for progesterone. If we need to administer progesterone to support the luteal phase or early pregnancy, I’m also asking why the body isn’t hormonally keeping up on its own. Are there holes in the nutrient bucket? Is she eating enough to support robust ovulation and hormone production? Is there significant stress or inflammation? Supplementing progesterone can provide valuable support, but it doesn’t necessarily address the physiology underneath why that support is needed.

And then there is thyroid. The conventional evaluation is largely looking at TSH, but TSH is one piece of a much bigger thyroid picture. Low free T3 or free T4 matters to me too, as does the presence of TPO or thyroglobulin antibodies. I also want to understand the nutrient factors required to make and convert thyroid hormone, alongside the gut, inflammatory and stress patterns that can complicate thyroid physiology in the first place.

THIS is the gap I see.

The classic recurrent loss evaluation gives us important information about recognized medical contributors to pregnancy loss. But my work doesn’t stop at identifying the abnormality alone and it definitely doesn’t stop when “everything looks normal”

I want to understand what is driving the pattern we’re treating.

And beyond that, I want to understand the availability of this woman, her partner and their collective physiology to receive AND sustain a pregnancy.

There are four areas I find myself coming back to again and again.

1. Depletion, reserves and the actual capacity of the female body

One of the first questions running through my mind with recurrent loss is: What has this woman’s body been asked to do — and what does she currently have available to do it with?

Multiple pregnancies or losses, retrievals and transfers, recent pregnancy or breastfeeding, under-eating, disrupted sleep, emotional stress, exercise and simply LIFE can all draw from the same reserves we are asking the body to use to ovulate, make hormones and sustain a pregnancy.

This is why I’m looking beyond whether her prenatal contains enough folate. Is she eating enough? What do her nutrient and mineral reserves look like? Is she ovulating robustly? Does she have the building blocks available to produce progesterone? How are her thyroid and stress-response systems adapting? Are there other stressors putting pressure and demand on her system?

And when it comes to thyroid, I care about more than a high TSH. Low free T3 or free T4 can give us important information about the thyroid picture, and I want to know whether thyroid antibodies are present rather than assuming a “normal” TSH tells me everything I need to know. I’m also thinking about the nutrients required to make, convert and utilize thyroid hormone and what could be interfering with that process in the first place.

This is where some of my deeper testing comes in:

• HTMA / Hair Tissue Mineral Analysis: gives me another lens into mineral patterns and relationships that can influence thyroid physiology, blood-sugar regulation, stress physiology and the broader hormone picture. I’m looking at the mineral foundation underneath capacity and resilience.
• DUTCH hormone testing: gives me a deeper look at sex hormones and their metabolites alongside cortisol patterns, helping me identify hormone and stress-response bottlenecks that deserve support in getting and staying pregnant.
• Advanced bloodwork: allows me to bring together a complete thyroid picture, iron and nutrient status, glucose and insulin regulation, inflammatory markers, liver markers and other pieces that tell me how well-resourced this woman actually is.

Because sometimes the question isn’t What else can we add? It’s:

Does this body have the reserves and resiliency to keep up with what we are asking it to do?

2. Gut health, inflammation and the physiological pressure on the body

This is another BIG area where I see women with recurrent loss fall through the cracks.

It is incredibly common in my practice to see gut inflammation, dysbiosis, maldigestion, constipation, bloating or other gut imbalances in women who have experienced recurrent loss. And I don’t see those as problems existing in a completely separate box from fertility. And to be honest, you don’t even have to have gut symptoms to have gut imbalances.

If the gut is inflamed or significantly imbalanced, that is another source of stress and inflammatory pressure on a body we are asking to support a pregnancy. And when digestion and absorption aren’t working optimally, it becomes harder to break down, absorb and utilize the very nutrients we need for hormone production, thyroid function, antioxidant defenses and pregnancy.

It’s all connected.

This is why I don’t want to simply throw more iron, magnesium, selenium, B vitamins or a bigger prenatal at a woman without also asking whether her body can actually digest, absorb and utilize what we’re giving her.

This is where GI-MAP testing can be incredibly valuable in my practice. It allows me to look more deeply at the gut ecosystem, digestion and patterns of imbalance or inflammation that could be adding pressure to the system or making it harder to replenish the woman in front of me.

And then there is another piece I pay close attention to in recurrent-loss cases that have been especially hard to crack: mold and environmental burden.

I have seen patterns of significant mold burden in some of my more complicated recurrent-loss cases. That does NOT mean mold explains every pregnancy loss or that every woman with recurrent loss needs mycotoxin testing. But I also don’t think environmental burden belongs completely outside of the fertility conversation.

Research gives us legitimate reason to care about mycotoxin exposure during pregnancy. Certain mycotoxins, including aflatoxins, can cross the placenta and have been associated with adverse fetal and pregnancy outcomes. The evidence specifically connecting individual mycotoxins to recurrent pregnancy loss is less established, so I don’t use mold as a singular explanation for miscarriage.

What I’m ALSO interested in is what a significant toxin burden is asking of the woman’s own system.

If her body is already navigating significant inflammatory, oxidative or immune pressure, her antioxidant systems and resources are being asked to work HARD. I want those resources available to support resilience, cellular health, egg quality and ultimately pregnancy rather than continually being drained by an unresolved burden.

In the right woman — based on her symptoms, history, home or work exposure and the rest of her clinical picture — mycotoxin testing can give us another piece of that puzzle.

I’m not looking for one thing to blame for a miscarriage. I’m asking:

What is putting unnecessary pressure on this body, and where can we reduce that pressure so more resources are available for resilience and pregnancy?

3. Male fertility — because “his semen analysis was normal” is not enough for me

This is probably one of my biggest pet peeves in fertility care.

A woman can undergo YEARS of investigation — bloodwork, ultrasounds, procedures, medications, retrievals, transfers, supplements and an enormous amount of responsibility for changing her body and lifestyle.

And then I ask about her partner and hear: “Oh, he’s good. His semen analysis was normal.”

That is not where the male fertility conversation ends for me.

A semen analysis is important. I want concentration, motility and morphology. But those numbers don’t tell me everything about the health of the man producing that sperm or what that sperm is bringing into conception.

Especially in recurrent loss, I want to understand his metabolic health, blood sugar, nutrient status, inflammation, sleep, alcohol intake, heat exposure, exercise, diet and environmental exposures. I want to know what could be increasing oxidative stress or compromising sperm quality even when the basic semen parameters look relatively good.

And depending on the history, I want to look at sperm DNA fragmentation too.

Because his contribution does not stop once a sperm successfully fertilizes an egg. Half of the genetic material of that embryo came from him, and paternal biology continues to matter beyond fertilization.

This is why I frequently use:

• Advanced male bloodwork: to look at glucose and insulin regulation, nutrient status, thyroid and metabolic markers, inflammation and other relevant patterns based on his individual history. Also holistically supporting his health picture -high blood pressure? gut issues? diabetes? all pieces we can be looking at here.
• A quality semen analysis: interpreted within the bigger clinical picture rather than reduced to “normal” or “abnormal.”
• Sperm DNA fragmentation testing: when the fertility and loss history gives us reason to look deeper.
• An actual diet and lifestyle assessment: because I’m not interested in automatically handing every male partner the same handful of antioxidants and calling his side of the equation handled.

If there is an opportunity to improve what HE is bringing into conception, I want that opportunity on the table before we put the entire burden of another pregnancy back onto her body.

4. The woman underneath the fertility journey

And then we get to the piece that no lab can measure — but in my opinion, cannot be overlooked in the recurrent-loss space.

Pregnancy loss is real grief.

And one of the things I see again and again is women being encouraged to keep moving forward before they have had any real opportunity to acknowledge and process what just happened to them.

Wait for your period. Try again. Start the next cycle. Schedule the next transfer.

There can already be such a sterility and conveyor-belt quality to the fertility world, and after loss, that pressure to keep moving can create an even deeper disconnection from yourself and your body.

Because this lives with you.

You were pregnant. You were beginning a relationship with that baby and imagining a future. And then that pregnancy ended. Whether the loss happened at five weeks, ten weeks or later, this is substantial. This is real grief. And it deserves somewhere to go.

I see women move into another TTC cycle carrying grief, fear and a profound lack of trust in their bodies while simultaneously being asked to track, test, perform, stay hopeful and open themselves to pregnancy all over again.

This is where my feminine-wisdom lens becomes just as important to me as the functional testing.How do we help her reconnect to herself after loss? How do we create more safety in her body rather than treating her body as the thing that failed her? How do we give grief somewhere to go? How do we reconnect her to pleasure, intuition, softness, desire and a life outside of fertility?

And how does she begin mothering herself while she is preparing to mother someone else?

THIS is what I mean when I talk about availability. It is NOT about being perfectly regulated. It is not about saying stress caused her miscarriage. And it is absolutely not about telling a grieving woman she needs to just “think positively”. It is about recognizing that after loss, there is a woman here who deserves to be tended to — not just a reproductive system we need to get pregnant again.

This is where nervous-system support, EFT/tapping, grief processing, self-connection and creating felt safety in the body can become part of the fertility plan alongside the labs, nutrition and medical care. I share resources with clients for 1:1 processing after loss and the grief that follows, because I think having real outside support to acknowledge and process this experience can be incredibly valuable here (and is often overlooked!)

And I have seen something important happen when women allow themselves to slow down, reconnect and regroup here rather than immediately pushing themselves back onto the fertility conveyor belt.

They start coming back to themselves.For me, THAT is functional nutrition meeting feminine wisdom. The physiology matters. The testing matters. The nutrients matter. The sperm matters. And so does the woman living inside of all of it.

What this has looked like in my practice

This isn’t theoretical for me. These are the pieces I have watched matter in the women and couples I work with — including women who came to me after recurrent loss, failed transfers or being told there wasn’t much else to investigate.

Meredith came to me after three unexplained losses, all before eight weeks. We were able to identify pieces of her fertility picture that had been overlooked, work on those areas before trying again, and she is now in her second trimester.

Nicole had been through two failed transfers and three miscarriages before we started working together. We spent time really getting underneath her fertility picture and addressing what had been missed before her next transfer. That transfer was successful, and she is now curving into her second trimester.

Joy had spent 2.5 years navigating recurrent loss without answers. Our work was really about finally uncovering the barriers that had been left on the table and giving her a different path forward C and she was able to get pregnant, stay pregnant and deliver a healthy baby girl.

Kristen came to me after two losses around 11–12 weeks — one connected to a chromosomal abnormality and another without an explanation. Instead of simply being told to try again, we used deeper testing to understand what her system needed and created a plan to help her prepare for her next TTC window. She is now in her third trimester.

Why I care so much about looking at all four

For me, this work is ultimately about partnering with your body. There are pieces of conception, pregnancy and loss that we will never be able to control, but there is also so much power in getting clear on what is within our control: what has been left on the table, what your body is asking for, and where we have an opportunity to create more availability to receive and sustain a pregnancy.

That can look different for every woman and couple. We might need to rebuild nutrient and mineral reserves, support the gut and reduce inflammatory pressure, look more closely at thyroid or hormone patterns, or bring your partner more fully into the fertility picture. Sometimes part of that work is creating the space to actually acknowledge and process what you have been through, reconnect with your body, and rebuild a sense of safety before asking yourself to move into another TTC window.

The intention isn’t to find one thing to blame for your losses or to convince ourselves that if we do everything “right,” we can guarantee what happens next. It’s to understand your whole picture and identify what is actually available to us to support. I want us to know where your physiology is asking for more, where there are barriers we can meaningfully address, and where we can create more capacity and resilience for what we are asking your body to do.

Because if, after all of that, the next step really is to try again, I don’t want you walking into that window feeling like you were simply told, “Everything looks normal. Good luck.” I want you to feel clear on what we have investigated and supported, connected to your body rather than at odds with it, and grounded in a greater sense of safety, alignment and confidence as you move forward.

That, to me, is creating more availability for pregnancy: partnering with your body, getting clear on what we can support, and moving into your next TTC window with intention and confidence in the path forward. If you are looking for a different perspective and support in this journey, I would love to connect with you to talk more by scheduling a Clarity Call here.