115. Miscarriage & Recurrent Pregnancy Loss: A Thoughtful, Cycle-Informed Evaluation

What if the most important step after pregnancy loss isn’t “try again,” but being truly seen and given a thoughtful plan? In this special episode for Pregnancy & Infant Loss Awareness Month, Dr. Monica Minjeur shares how restorative reproductive medicine supports women with cycle-informed evaluation, timed hormone labs, thyroid and insulin testing, male factor assessment, and screening for chronic endometritis—often missed in standard care. With compassion and clarity, discover how to build a plan that honors your grief while restoring your body’s ability to heal and conceive.

Key Takeaways

• Compassion first: Honor grief, name the baby if desired, and move at your own pace.
• Cycle-informed evaluation: Use charting to assess ovulation return, luteal phase strength, fertile signs, and bleeding patterns (especially brown bleeding).
• Timed hormone labs: Check progesterone and estradiol ~7 days after ovulation to assess ovulation quality—not just “day 21” labs.
• Thyroid & insulin matter: Full thyroid panel (TSH, Free T4, Free/Total T3, antibodies) and insulin testing (fasting or OGTT with insulin).
• Screen for chronic endometritis: Especially if there’s brown bleeding, early loss, or heavy cycles. Consider menstrual testing, biopsy, or hysteroscopy.
• Male factor is essential: Include semen analysis and DNA fragmentation testing, even if conception occurred.
• Re-testing is critical: Confirm improvements after treatment—labs, charting, and symptom resolution all guide timing.
• When to try again: A shared decision—emotionally ready, physically supported, with a clear plan for early pregnancy monitoring (HCG, progesterone, estradiol).

If you’ve experienced pregnancy loss and feel like you’re navigating it alone or without answers, we’re here to help. At Radiant Clinic, we combine compassionate care with cycle-informed, restorative evaluation to create a plan designed for your body and your story.

 Schedule your free discovery call at radiantclinic.com

Transcript

Speaker: 0:01

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if the most important thing after a pregnancy loss isn't trying again, but being seen, being heard, and having a clear but gentle plan for your next steps. In honor of pregnancy and infant loss awareness month. Today we're going to talk about compassionate care after loss, what to evaluate, how to support healing, and how restorative reproductive medicine plans the next steps with dignity and hope. So let's talk today about a patient's story, and we'll call her Elise. Now Elise came to see me at 32 years of age, and she had had a first uneventful pregnancy with a beautiful, healthy baby girl. She and her husband wanted more children though. However, the next three pregnancies tragically ended in miscarriage between six to eight weeks. When Elise came to see me, she said she felt numb and guilty and overwhelmed, especially by the well-meaning comments of friends and family. People said things like, at least you have one child, or maybe this one wasn't meant to be, rather than all the comments. She just wanted space to grieve and also to find real answers. At her follow-up visits with her OB doctor, she was told everything looks fine. It's probably just a genetic issue. You can try again in a few months. No plan, no labs, no timing. Luckily, a friend referred Elise to our clinic where the initial visit was different. We listened. We honored her story and mapped out a gentle evaluation that was matched to her cycle. As always, we began cycle charting right away to help understand her bleeding patterns, the fertility window when ovulation returned, and to assess all the different phases of her cycle. We drew timed labs to her specific cycle and found that she had suboptimal levels of both progesterone and estradiol in her luteal phase. Although she had a normal TSH part of the thyroid hormone panel, she had low T three levels and she also had fasting insulin levels, although she had normal hemoglobin A1C and blood sugar readings. We additionally found that she had brown spotting at the end of her cycles and a history of heavier bleeding. On day one, we did complete evaluation for chronic endometritis, which revealed bacterial and yeast overgrowth. Our care plan included treatment of the chronic endr. Support of her hormones during her luteal phase, balancing and improving all of her vitamin levels, like vitamin D and iron depletion, and a gentle nutrition strategy with resistance training to help with the insulin resistance. Two cycles after her antibiotic treatment for the chronic endometritis. Elise's charts have showed more clear fertile signs and a stronger luteal phase. As soon as she is emotionally ready, she has the green light to conceive, but this time with a more clear path to monitoring her hormone levels during pregnancy so she can feel supported every step of the way. So what comes first? What do we need to consider anytime that somebody has a pregnancy loss? We always want to give people space to mourn, to grieve, to name the baby if desired, and to normalize the mix of emotions. We see everything from complete grief and devastation to numbness, to kind of just not really knowing what to think, and we want to give people the space to feel their feelings. We also want to encompass what it looks like to have actual medical evaluation, and it's important even with a single loss. We know that not every test is needed right away, but we're going to talk through a few different things that we want to pay attention to, especially if we are guiding them with clear clinical clues. Things like spotting or brown bleeding, irregular or painful cycles, thyroid symptoms, insulin resistance, all of these things that we've talked about, and many of them can be identified even prior to trying to conceive again. Okay. We do an expanded workup if there's been a recurrent loss, so anything that is two or more clinically recognized losses. And in those cases, we also discuss male factor evaluation. So we're going to break this down a little bit and kind of talk through what are the things we want to check and things that you need to make sure are a part of your evaluation. Now, I realize that many people have gone through a loss and may not have been offered this full evaluation, and so I want to encourage you that it is absolutely appropriate to get evaluated at any point in time. This does not necessarily have to happen right after a loss. So after any loss, even your first loss, we do selective evaluation. Guided by your charting, guided by your symptoms. So the first thing, again, we always look at cycle charting. We want to track when ovulation returns. We want to evaluate if you have any brown bleeding or spotting that's happening between your menstrual cycle. We also evaluate the quality of your mucus during your fertile window and your luteal phase length. So the time from when you ovulate until your next cycle begins. All of these things that we can pick up on your cycle charting, give us important clues to evaluate what else you need for additional evaluation. We always will typically additionally check luteal, phase hormones, progesterone, and estradiol. And again, not just checking a cycle day 21 test, but timing labs specifically to be seven days after ovulation. This is typically when we would see the peak or the highest point, specifically of those progesterone levels, and it helps us to assess the quality of your ovulation, not just if it happened or not. We also do additional evaluation of your stress hormone, so looking at those adrenal glands to evaluate cortisol, DHEA levels and testosterone levels, all of these things can give us important insight as to where we might need to help support your body prior to an upcoming pregnancy. We also do a deep dive when it comes to thyroid. Looking at a full thyroid panel that needs to include more than just A TSH. We also check free T four. We check T three levels. We also look for thyroid antibodies like thyroid peroxidase. And thyroid globulin. Many, many times we see women come into our practice that are told their thyroid gland is normal, and all they've had done is A TSH. And I want to reiterate, this is not a complete test and oftentimes misses important pieces of the thyroid picture. We also take a look at metabolic factors, things like your fasting insulin levels, and maybe an oral glucose tolerance test. Along with insulin levels, we oftentimes see that fasting blood sugar and hemoglobin A1C can be completely normal, but if insulin levels are high, that can impair the quality of ovulation. We also look at your nutrient levels to determine absorption, to make sure that you aren't depleted of important nutrients like ferritin, which is your iron stores, vitamin D, vitamin B12, and folate levels if needed, to make sure that you have everything you need in order to help support that upcoming pregnancy. And finally, we're also going to be looking at that uterine environment. So as was the case with Elise, consider evaluation and screening for chronic endometritis if you have irregular spotting patterns, brown bleeding, very heavy cycles or prior failed implantations. So early miscarriages. We can do this either through menstrual blood sampling, and there are many companies that are starting to do this where they send you a kit, you collect your menstrual blood at home, and then you send it back in for evaluation. You can also have an endometrial biopsy or hysteroscopy done to evaluate for chronic endometritis. Now, we don't necessarily do every single one of those things every time, but again, we want to look at what your cycle shows us, what symptoms you have, and really do a deep dive to evaluate where do we need to focus more attention. Now, if you've had two or more pregnancy losses, then we wanna start digging a little bit deeper. And so absolutely, we would check all of those same things we would initially look at with a first loss, but we also want to consider a couple of other factors in as well. So one thing that often gets overlooked is male factor, and many people believe that since you were able to get pregnant, there's no male factor. Now the reality is you can have sperm present and you can still have male factor that's playing a role when it comes to recurrent miscarriage or pregnancy loss. So in addition to checking a semen analysis, we also will evaluate a DNA fragmentation test. Now, this again, looks for the quality of sperm to make sure that the adequate DNA material that's being presented is appropriate to be able to carry on that pregnancy. We also look at lifestyle factors for the male partner, including optimization of sleep, eliminating toxins, making sure they have appropriate nutrients in their diet, avoidance of heat, and evaluating other metabolic factors that can also play a role when it comes to ensuring we have good quality sperm that are present. In some cases, we're also going to look at things like antiphospholipid syndrome, lupus, anticoagulant, anticardiolipin antibodies. Many of these things can cause coagulopathy or micro clots, or can cause excessive bleeding in other situations, and so we want to evaluate some of those things that can have a genetic link that may be overlooked. In some cases, we also discuss targeted ultrasounds or saline infused sonography to look for other abnormalities that may be going on in the uterine cavity. We evaluate for things like polyps or fibroids or abnormal shape of the uterus itself if this has not already been evaluated. And finally, in some cases we'll discuss parental karyotypes. So checking the actual genetic material of mom and dad to determine if there are particular things that may be playing a role from a genetic standpoint that may be playing a factor when it comes to these recurrent pregnancy losses. Again, we want to make sure that every evaluation that we're doing has a repeat assessment done. So whether that is repeating the lab testing, looking at ultrasounds again, ensuring that we are seeing a clearing of abnormal bleeding on charting to make sure that endometritis is gone. All of these things require additional assessment. Now one final feature that I will mention that can be very difficult to diagnose and treat is endometriosis. Now, we recently talked a lot about endometriosis a few weeks ago, and so you understand why it's a little challenging to diagnose it, but endometriosis itself can cause problems as far as recurrent pregnancy loss. And we think that this can happen through inflammation and the troubles with implantation itself, and in some cases it can happen with impairing fertility in the first place. So sometimes people don't get to that miscarriage, but that absolutely can still be a role when it comes to recurrent pregnancy loss. Now, this can be a little challenging because in. Some women, they don't have any symptoms at all of endometriosis. And in others, the only symptom we may see may be irregular bleeding or pain with their periods. So again, another important factor to make sure that we don't forget is to evaluate. Do we need to have concern for endometriosis? So I often get asked after we've gone through all of this evaluation, after we've corrected everything that we can find, when do we try again? And really this becomes a shared decision making process. One of the most important pieces with this that I discuss with couples is, are you emotionally ready? And what I mean by that is if you were to get pregnant again and suffer another pregnancy loss, how would you handle that? We also want to have a clear plan going forward as to when you do have that positive pregnancy test, what are the steps that we need to do to make sure we are continuing to address and balance your hormone levels? Specifically looking for progesterone, estradiol levels, and HCG monitoring. How are we going to manage that, monitor that, and give intervention when it's appropriate? We also want to make sure that we have taken care of your overall health needs by addressing you as a whole person, making sure you're sleeping well, you're able to exercise in a good way. You have the support you need from a standpoint of managing your grief or trauma that you've been through in the past. And what are the tools you're using currently to help address stress levels? Because stress can play a huge role when it comes to trying to conceive again. Ultimately, there is no magic answer as to when is the appropriate time to try and conceive again. And so for each couple, we walk through the process with them to determine what feels right. We generally will tell people, start your charting again. When you're ready, we'll match up your testing to your ovulation and your cycle day when it's appropriate. If you notice any problems with irregular bleeding or brown bleeding or spotting, make sure that you're charting that because that can be an important clue as to what's going on with your cycles. Always request a complete and detailed lab evaluation, and most importantly, timed to your cycle. If you have had recurrent losses, discuss any additional deeper level testing and make sure that male factor plays a role with that. And most importantly, make sure that you are rechecking after any treatment to verify improvement and to make sure that your levels are truly optimized before trying again. Now finally, I'd like to include just a little section about language that may or may not be helpful if you have somebody in your life who has experienced a pregnancy loss or recurrent miscarriage. So things that we hear from our patients that are helpful include, I'm sorry, I'm here with you, validating that your grief is real and there's no timeline as to when you need to stop grieving. Or saying, Hey, I'd be happy to help you look for answers together whenever you're ready. In some cases, people want to name their baby and so asking, would you like me to use your baby's name when we're discussing what happened? Things that we find are definitely not helpful include some of the comments that Elise had heard. At least you can get pregnant, or at least you have a kid already, or at least it was early. Other things that we find are not helpful, everything happens for a reason, or you can always try again. And ultimately, anything that's an unsolicited fix or comparison story or saying, oh yeah, well, I dealt with that too and I'm fine. Now for the most part, these are typically not welcome language. So things that you could try instead, and especially if you're somebody who is supporting somebody who is walking through a miscarriage, or maybe you're a healthcare professional who is helping people to navigate loss. One of the most helpful things that we try to say is, if today is too much for decision making, we can just talk and we can always plan later. Or asking, would it be helpful if I explain what we can check and we can decide together what's right for you? Most importantly, giving you the space to make those decisions if and when the time is right and ultimately honoring the decision that some people make to not try and conceive again, and that is perfectly okay. Imagine if your grief was honored. While a thoughtful cycle timed evaluation could help to uncover what your body needs next, over the coming months, we can evaluate what happens with your charting, clarify all of the different phases of your cycle, and help to show lab progress over time. Each of these steps can help to restore trust in your body for a deeper understanding to help improve health. And promote fertility.