Unexplained Infertility

Key concepts of unexplained infertility

Unexplained infertility is the diagnosis given when conception does not occur after more than one year of trying, but tests do not identify the exact cause.

This is a common finding, with about 30% of couples who have trouble conceiving being diagnosed with unexplained infertility.

Unexplained infertility is treatable, and most couples and individuals with this diagnosis who follow their doctor’s recommended fertility treatments can have a child of their own.

These treatments depend on the individual circumstances and include medications for ovulation stimulation, with or without IUI (intrauterine insemination), and in vitro fertilization (IVF).

Patients can also undertake lifestyle changes to improve their chance of conception.

Understanding unexplained infertility

Fertility specialists give a diagnosis of unexplained infertility when fertility tests, a patient’s medical history, and clinical insights do not indicate a clear reason why a couple or individual are not able to conceive. Reproduction is a complicated process with many factors, male and female, that can inhibit successful pregnancy and birth. It is not always possible to pinpoint a cause, or causes, of infertility.

According to the American Society for Reproductive Medicine, unexplained infertility occurs in 30% of infertility cases. This is a common diagnosis.

Addressing the unique stress of this diagnosis

We understand that receiving a diagnosis of unexplained infertility can be more difficult for patients than receiving other, more specific infertility diagnoses. This can add to the emotional strain of not being able to conceive.

It can be frustrating not to know the cause of any medical problem. This uncertainty can make it difficult to commit to moving forward with a treatment when the cause is not understood.

Our fertility specialist Dr. Isaac Glatstein works closely with patients to help them adjust to this unknown and understand that the diagnosis is treatable. He explains that by utilizing information from tests, knowledge of the patients’ history, and his observations and experience, he creates a fertility treatment plan patients can feel comfortable about.

Unexplained infertility causes and diagnosis

The cause of unexplained infertility can be any of the same factors that cause other forms of infertility. We won’t really know the cause until a treatment has been effective. It is possible that we will never know the cause, if treatments attempted don’t result in pregnancy.

But the first step in arriving at this diagnosis is conducting a thorough medical history of the partners or person, as well as genetic history for them and their family. A semen analysis is done for the male.

We conduct a physical exam of the female looking for structural issues and evaluating her ovulation. Blood work is done to evaluate the balance of reproductive hormones.

Hysterosalpingography (HSG)

A hysterosalpingography, also called a hysterosalpingogram, evaluates the woman’s uterus and fallopian tubes to determine if any issues there are causing infertility. This involves insertion of a hysteroscope through the cervix with a contrast dye that allows for better viewing.

Arriving at a diagnosis

After those tests are inconclusive, we typically arrive at the unexplained infertility diagnosis when:

• The woman has at least one functioning fallopian tube, signs of normal ovulation, and no condition such as endometriosis or uterine fibroids.
• The man’s semen analysis indicates a healthy quality and quantity of sperm.
• Neither partner has structural problems in the reproductive system or irregularities with reproductive hormones.

Because both male and female factors affect conception, we evaluate both partners before making this diagnosis. A single individual and LGBTQIA+ patients can also get this diagnosis.

Treating unexplained infertility

Treating this form of infertility is unique as the underlying condition is not known: All infertility treatments are options. Determining the right treatment calls for empirical medicine, which means the doctor relies on experience treating this condition among different patients, assessing observations made, and a trial-and-error approach to some degree.

We discuss all options with the patients, also taking into consideration their time frame for an expected child, their emotions and preferences.

How successful is treatment?

One study by the National Institutes of Health reports that 92% of couples with this condition eventually had a child after fertility treatments. Of the treatments that follow, IVF is the most successful at over 50% followed by gonadotropin with IUI, clomiphene with IUI and clomiphene alone being successful under 5% of the time

Following are treatment options.

Ovulation stimulation drugs & intrauterine insemination

Drugs that stimulate egg production over the normal one per month, such as clomiphene (Clomid) and letrozole (Femara), can be helpful. Ovulation induction can be done along with IUI, which places the sperm in the uterus at the time of ovulation.

Injections of the gonadotropin hormone also stimulate ovulation and are effective with low sperm count. These injections may be used with IUI.

IVF for unexplained infertility

IVF, in which fertilization occurs in the lab, is the most successful treatment for unexplained infertility. Success rates for IVF as a first treatment are around 55%, according to the National Institutes of Health. Several factors are involved in whether to pursue IVF, including age of the woman, her ovarian reserve and general health.

IUI costs less and requires less time from the patient, but multiple IUI cycles may be necessary. IVF, with the ability create and freeze more than one egg or embryo per cycle, can offer more opportunities for children. When the woman is over age 35 and desires more than one child, IVF is likely to be the initial treatment.

IVF with ICSI and PGT

Along with IVF, intracytoplasmic sperm injection (ICSI) can be beneficial particularly in cases with questionable or known male sperm issues. That’s because ICSI injects a healthy sperm into the egg’s cytoplasm where fertilization occurs.

Preimplantation genetic testing (PGT) of the resulting IVF embryo can increase the chances of successful pregnancy. PGT can identify genetic defects in embryos that can result in failed implantation, miscarriage or birth defects in a child.

Timing intercourse for the fertility window and lifestyle solutions

Some couples with unexplained infertility can still become pregnant on their own. Knowing how to time intercourse to coincide with the fertility window around ovulation is beneficial in this respect.

Lifestyle actions such as both partners maintaining a healthy weight can be helpful for those with unexplained infertility. Women should not smoke and should limit alcohol and caffeine consumption.

In conclusion

While this is a challenging diagnosis for patients to receive and for doctors to treat, it is treatable. After we gather all information, we discuss a tailored plan with each patient. These will be different depending on the individuals’ conditions and their desires. From lifestyle changes an individual can employ to the most advanced fertility treatment of IVF, we can help patients overcome unexplained infertility to have a family.