Unexplained Infertility: What Can You Do. Advice and Guidance

Infertility is a condition that affects millions of couples worldwide. While many cases of infertility have identifiable causes, about 10-20% fall under a perplexing category known as “unexplained infertility.” This term is used when a couple fails to conceive after one year of unprotected intercourse, despite having no diagnosable reproductive issues. This can be a particularly frustrating diagnosis, as it provides no clear path to treatment or understanding. In this article, we will delve into what unexplained infertility is, its potential causes, and the options available for those affected.

What Is Unexplained Infertility?

Unexplained infertility is diagnosed when standard fertility tests do not reveal a clear reason for a couple’s inability to conceive. This can include normal ovulation, clear fallopian tubes, normal sperm count, and no evident uterine abnormalities. Despite this, the couple still faces challenges in achieving pregnancy. It is important to note that “unexplained” does not mean there is no cause; rather, it means that current testing methods have not been able to identify one. In my experience many cases of so called “unexplained infertility” do in fact reveal causes when investigated in a specialist unit. For example, I explained in my article on Endometriosis that many patients referred to our unit stating “no evidence of endometriosis” on full assessment did in fact have endometriosis.

Potential Causes of Unexplained Infertility

Although the exact causes of unexplained infertility remain elusive, several potential factors may contribute:

Subtle Ovulatory Disorders: Even when regular ovulation appears normal, there can be subtle hormonal imbalances or irregularities in the ovulation process that are not easily detected by standard tests.
Sperm Function Issues: While a semen analysis might show a normal sperm count, motility, and morphology, there can be issues with sperm function that are not identified in routine testing. This can include problems with the sperm’s ability to penetrate and fertilize an egg.
Egg Quality: The quality of a woman’s eggs can decline with age or due to other factors that are not always apparent through basic fertility tests. Poor egg quality can affect fertilization and embryo development.
Immunological Factors: The immune system may sometimes react to sperm or embryos in ways that prevent conception or lead to early pregnancy loss. These immunological issues are not typically covered in standard fertility evaluations.
Endometrial Receptivity: The lining of the uterus (endometrium) must be receptive to the embryo for implantation to occur. Subtle issues with endometrial receptivity may not be detected through routine tests.
Genetic Factors: There may be unknown genetic factors that affect fertility, either in the eggs, sperm, or embryos.
Lifestyle Factors: Diet, exercise, stress levels, smoking, alcohol, and exposure to environmental toxins can all play a role in fertility, even if they do not cause specific medical abnormalities. Diet is difficult to evaluate but may play a significant part in infertility. The main message here is everything in moderation.
Endometriosis is a chronic and often painful condition affecting millions of women worldwide, often leading to significant challenges in fertility and pregnancy. Tissue similar to the lining inside the uterus, known as the endometrium, starts to grow outside the uterus. Endometriosis causes infertility in about 30-50% of women who are diagnosed with it. The effects of endometriosis do not correlate with the size of the lesions. Some patients have large growths and little symptoms others a slight sheen of endometriosis and severe symptoms.

Diagnosis and Testing

Despite the frustration of not having a clear cause, it’s essential to undergo thorough testing to rule out known factors:

Ovulation assessment: Checking for regular ovulation through hormone tests and tracking menstrual cycles.
Semen Analysis: A detailed analysis of sperm count, motility, and morphology is essential.
Hysterosalpingography (HSG): This test checks the fallopian tubes for blockages and assesses the shape of the uterine cavity.
Laparoscopy: In some cases, a minimally invasive surgery called laparoscopy is performed to check for conditions like endometriosis that might not be detected by other methods.

Hormonal testing: To check levels of thyroid hormones, prolactin, and other key hormones involved in reproduction.
Diet evaluation: to check for dietary imbalance.

Treatment Options for Unexplained Infertility

Even without a specific diagnosis, several treatments can enhance the chances of conception:

Lifestyle Modifications: Before moving to medical interventions, addressing lifestyle factors such as diet, weight management, reducing stress, and avoiding smoking or excessive alcohol can help improve fertility.
Ovulation Induction: Medications like Clomid (clomiphene citrate) or Letrozole can stimulate ovulation, increasing the chances of pregnancy.
Intrauterine Insemination (IUI): This procedure places sperm directly into the uterus, closer to where fertilization occurs, and is often combined with ovulation induction.
In Vitro Fertilization (IVF): IVF is often recommended for couples with unexplained infertility, especially if other treatments have failed. IVF involves retrieving eggs and sperm, fertilizing the eggs in a laboratory, and transferring the resulting embryos into the uterus. Unfortunately, these days IVF is often seen as synonymous with infertility, without thorough testing. Current evidence does not support IVF as a first-line therapy for unexplained infertility.
Advanced Testing: In some cases, more specialized tests, such as those assessing sperm DNA fragmentation or endometrial receptivity assays, may be considered to identify subtle issues that could be impacting fertility.

For most couples with unexplained infertility, the best initial therapy (following comprehensive investigation) is a course (typically 3 or 4 cycles) of Ovarian stimulation (OS) either with clomiphene or letrozole and Intrauterine Insemination (IUI).

Coping with Unexplained Infertility

Dealing with unexplained infertility can be emotionally taxing. The uncertainty and lack of answers can lead to frustration, anxiety, and feelings of helplessness. Here are some strategies that may help:

Seek Support: Connecting with others who are going through similar experiences can provide comfort and understanding. Consider joining support groups or seeking professional counselling.
Educate Yourself: Knowledge is empowering. Learning more about infertility and available treatments can help you make informed decisions and feel more in control of your situation.
Communicate with Your Partner: Open and honest communication is vital. Infertility can strain relationships but facing it together can strengthen your bond.
Consider All Options: Be open to exploring all available options, including alternative therapies, adoption, or choosing to live a fulfilling life without children.

Conclusion

Unexplained infertility remains one of the most challenging diagnoses in reproductive medicine. With the right approach, including thorough testing, treatment, and emotional support, many couples go on to have successful pregnancies. Advances in fertility treatments continue to improve outcomes, offering hope to those navigating this complex and often frustrating journey. Understanding your options and staying informed are key to navigating this challenging journey.

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