Unexplained infertility is by far the most frustrating of all conditions I see. To get this diagnosis, all the testing patients have undergone show that everything is normal. There are adequate sperm for the male, and female patients seem to be ovulating or “making eggs.” The “plumbing” has been checked through an ultrasound and hysterosalpingogram, or “dye test,” and there are no abnormalities. We cannot find a medical reason for failure to conceive.
I have sat before many patients with this diagnosis, including many that are in the medical profession, and the look of utter frustration is intense. They say “Everything checks out, so why won’t it all work?” The fact is that as many as 20 to 30 percent of all the patients we treat for infertility are not truly explained. The patients look to us for a treatment plan, but what are we treating? Doctors, as a general rule, like to know what and why they are doing things before they do anything. But unexplained infertility defies that rule because the lack of a plan of action is unacceptable. So, we need guidelines.
Clearly, if you do not know what you are treating then anything you do is empiric. In other words, we will rely on observation and experience rather than clear cut science. The general rule is if the woman is 35 or younger, and there is a normal semen analysis, doctors should provide Intrauterine Insemination (IUI) three times. That yields about a 30 to 35 percent overall pregnancy rate after three attempts.
If IUI fails, you move on to IVF for 3 attempts. The combined IUIx3/IVFx3 yields between 85 and 90 percent success rate. But, if the semen analysis is significantly abnormal, or if the woman is older (or there is evidence of a diminished egg reserve), you should recommend going straight to IVF.
Obviously, patients have choices. There have been many patients who have insisted on trying IUI first, and some who wanted to skip the IUIs and go straight to the most effective tool we have, In-Vitro Fertilization. Medical ethics dictate that the choice must be made by affirming “patient autonomy” and the “Doctor’s Beneficence.” That means the patient should be involved in making the choice, but the doctor can only do what has a real chance of working.
Before I initiate a treatment plan, I review the history closely, especially the family history. It is my experience that many unexplained infertility patients are in fact getting pregnant, but they are miscarrying and do not know it. Incredibly, a study showed that probably 70 percent of all pregnancies never make it. The woman may get her menstrual cycle on time or may not. It may come a few days late, the patient may feel that the breasts are tender and may think to themselves that it doesn't come tomorrow I will run out and buy a pregnancy test. Then the menstrual cycle starts.
In other words, I believe that many of these patients are in fact getting pregnant but repeatedly losing pregnancies. Recurrent pregnancy loss, however, is the subject of an entire different blog. Regardless, I very often if not always look at the possibility that the patient is experiencing recurrent pregnancy loss. It’s extremely important - imagine finding out you have a treatable recurrent miscarriage condition after losing viable IVF pregnancies.
Unfortunately, no doctor can find answers for every patient. Sometimes unexplained infertility, despite our best efforts and the use of the latest technology and tests, stubbornly remains unexplained. For those patients, gestational carriers or adoption may be their best paths to parenthood. As disappointing as this can be, the good news is that more than 50,000 people in the U.S. every year become parents through these methods. The path to parenthood can be a rocky one, and those who battle unexplained infertility certainly have among the rockiest of journeys, but in most cases there can be a happy ending.
