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Even when conditions are optimal, the maximum chance of a clinically recognized pregnancy occurring in a given menstrual cycle is 30–40%. Increasing evidence points to preclinical pregnancy loss rather than failure of conception as the principal cause for the relatively low fecundity observed in humans. While sensitive assays for hCG have provided a glimpse of the events occurring between implantation and the missed menstrual period, new cytogenetic techniques have further opened this ‘black box’, providing novel insights into the causes of early pregnancy wastage. In this article, the evidence and causes of preclinical or ‘occult’ pregnancy are reviewed, and the implications for the infertile patient are addressed.