After a loss, and trying again

No, it was not the thing you keep going back to

If you are here at three in the morning going through the week before, start with this: almost none of what people replay is capable of causing a first-trimester loss.

Not lifting something heavy. Not the glass of wine before you knew. Not sex. Not the argument, the deadline, the flight, the hot bath, the workout, or not resting enough. Not a food you ate.

ASRM's figure is that genetic abnormalities are responsible for up to sixty percent of first-trimester losses. Those are errors in cell division that were settled at conception — before that week, before anything you did or did not do in it, and before you knew there was anything to protect.

The reason this is worth saying first is that the search does not stop on its own. It waits for something to answer it.

The odds, which are better than they feel

ASRM's figure is worth reading twice: even after having three miscarriages, a woman has a sixty to eighty percent chance of conceiving and carrying a full-term pregnancy.

That is after three. Most people reading this have had one, where the outlook is better still.

It does not make a loss smaller, and it is not offered as consolation. It is offered because the fear after a loss reliably outruns the actual odds, and the actual odds are on your side.

When it has a name, and what that changes

ASRM defines recurrent pregnancy loss as two or more clinical pregnancy losses before the pregnancies reach twenty weeks.

Having a definition is more useful than it sounds. It gives you something to say — that you meet the criteria for evaluation — instead of having to argue for being taken seriously.

If you have had two losses, asking what an evaluation would involve is a reasonable request, not an overreaction.

Why the cause is so often not found

ASRM groups the known causes into genetic abnormalities, anatomic issues such as uterine shape problems, a septum or fibroids, lifestyle factors, and medical conditions including thyroid disease, diabetes and immune or clotting disorders.

But the largest category is none of those. Unexplained causes account for over half of recurrent loss cases.

That is the hardest part of the whole process — an investigation that finds nothing feels like being told there is nothing to fix. It is worth reframing: a normal set of results also rules out a long list of things, and unexplained loss still carries the sixty to eighty percent figure above.

The other number to sit with: genetic abnormalities are responsible for up to sixty percent of first-trimester losses. Those are chance events in cell division, not consequences of anything anyone did or failed to do.

Inflammation: one real link, and a lot of noise

This comes up constantly in searching, and it deserves a straight answer, because the honest version has two halves that point in opposite directions.

The real one is chronic endometritis — a persistent, mild inflammation of the lining of the uterus. A 2024 systematic review and meta-analysis in Frontiers in Immunology pooled nine studies covering 1,038 women and found it in 37.6% of recurrent-loss cases against 16.4% of controls, an odds ratio of 3.59 (95% CI 2.46-5.24), with no heterogeneity between studies. Their conclusion was a strong association between chronic endometritis and recurrent pregnancy loss.

It is worth knowing because it is diagnosable — the reliable marker is plasma cells in the endometrial tissue — and because it is treated with antibiotics rather than anything exotic. If you have had recurrent losses, it is a reasonable thing to ask whether it has been considered.

The honest limitation, which the authors state themselves: this is an association from a small pooled sample, definitions of recurrent loss differed between studies, and there is no universally accepted threshold for how many plasma cells count. Critically, that review measured how OFTEN it is present, not whether treating it improves outcomes — those are different questions, and the second is the one that matters to you.

The other half is the noise. Inflammation is the hook for a large market in immune testing and immune treatment for pregnancy loss — panels, intralipid infusions, steroids. ASRM's updated recurrent-loss guidance, its first in over a decade, points the other way: it recommends chromosome testing of miscarriage tissue as a first step, targeted testing based on your own history and risk factors, and avoiding routine use of tests and treatments that lack strong evidence of benefit.

So: ask about chronic endometritis specifically, by name. Be more careful with anything offered as a general anti-inflammatory or immune protocol, particularly if you are paying for it directly.

The things people blame themselves for

Almost none of it holds. Lifting something, a glass of wine before you knew, a stressful week at work, exercising, an argument, not resting enough — these are the things people replay at three in the morning, and they are not what caused a first-trimester loss.

The cause is most often chromosomal and was determined long before anything you did that week.

If someone has implied otherwise, or if you have implied it to yourself, that is worth naming rather than carrying quietly. It is also a legitimate reason to ask for support — grief after a loss is real grief, and it does not require anyone's permission or a particular number of weeks to justify it.