Unexplained Infertility

Unexplained infertility at a glance

• Unexplained infertility is the diagnosis fertility specialists give an infertile couple or individual when available diagnostic tools have failed to detect a specific cause.
• We make this diagnosis when key reproductive elements appear to be in order but the couple or a woman is not conceiving.
• Unexplained infertility is a common cause of infertility, and according to Fertility and Sterility, up to 30 percent of infertile couples will be diagnosed with it.
• This nonspecific cause of infertility can often be effectively treated, with methods including continuing to try natural conception, medications such as Clomid, intrauterine insemination (IUI), and in vitro fertilization (IVF).

What is unexplained infertility?

Patients receive an unexplained infertility diagnosis after a fertility workup of the couple or individual finds no known cause for the infertility. It can be a distressing diagnosis (see section below).

A couple unable to conceive receives an unexplained infertility diagnosis when:

• The woman is ovulating regularly.
• She has at least one open fallopian tube.
• The man has a normal semen analysis.
• And their exams have found no other pathology, such as uterine fibroids in the woman or structural issues in the male.

Unexplained infertility does not mean there is no cause for a couple’s or patient’s infertility. It just means that our diagnostic tools and examinations have failed to detect the cause. The woman could have issues with cervical mucus, with egg quality or with the ability of the uterus to allow an embryo to attach.

Though unknown at the time of an unexplained infertility diagnoses, fertilization barriers are often a key player. This can be identified as the most likely type of cause when the couple has failed to conceive after three attempts at IUI.

Twenty percent of women with unexplained infertility will have endometriosis. Endometriosis can have multiple negative impacts on fertility by decreasing egg quality, fertilization rates and implantation rates.

Genetic issues can also be tied to unexplained infertility, as can subtle fallopian tube defects, but these are thought to be relatively rare.

Diagnosing unexplained infertility

A number of steps are standard in arriving at a diagnosis of unexplained infertility.

• Complete medical history of the male and female. This should include their genetic history and their families’.
• We will conduct a semen analysis and physical exam on the male. We’ll do a physical exam and pelvic anatomy exam for the female that includes assessment of ovulation by measuring key hormone levels and use of ultrasound to detect abnormalities such as fibroids.
• A hysterosalpingogram (HSG), involving an hysteroscope inserted through the cervix and a contrast dye, helps us detect issues in the uterine cavity and fallopian tubes. Careful HSG can detect abnormalities that fertility specialists used to look for with diagnostic laparoscopic surgery.

The emotional burden of unexplained infertility

An unexplained infertility diagnosis can trigger a range of emotions. While trying to get pregnant, patients can be under considerable pressure. They may experience feelings of losing control, financial strain, martial stress, in addition to pressure from friends and family members to get pregnant.

We understand that couples and individuals can become extremely frustrated that they don’t know the cause of their infertility. It can be psychologically difficult to deal with the concept of needing some kind of treatment but not being sure exactly for what. Having a treatment recommended when the doctor can’t identify the cause of the problem can cause patients to lose faith in their fertility specialist.

Before proceeding with a treatment option, TRM fertility specialists have a thorough discussion with the couple or individual about their particular situation.

Unexplained infertility treatments

Patients with unexplained infertility have every treatment option open to them. For our patients, which treatment option we recommend – including no treatment with the couple continuing to try conceiving on their own – comes down to their goals. It’s important that we discuss that with them, including their finances and emotions. We take treatment for unexplained infertility one step at a time, with doctor and patient working together.

For example, if a woman with unexplained infertility is age 35 and wants two children, it might be better to start IVF sooner rather than later. If we collect a good amount of quality eggs, this effectively freezes her biological clock. However, some couples like to start with more conservative approaches first.

Following are treatment options in addressing unexplained infertility, beginning with steps patients can undertake themselves.

Timed sexual intercourse

This is a good option for couples and individuals who want to continue to try to conceive on their own. We help them understand the optimal way to have sexual intercourse timed to ovulation to increase chances of natural pregnancy success.

Lifestyle changes

These changes can increase fertility and are good steps to take no matter what treatment option patients take. Women should stop smoking, limit alcohol consumption and reduce caffeine consumption. Both men and women should maintain a healthy weight.

Ovulation stimulating medication

Clomid (clomiphene) is a drug in pill form that stimulates a woman’s ovaries to produce more than the normal one egg per cycle. We often combine Clomid with IUI, a form of artificial insemination that places the sperm in the uterus at the proper “fertility window,” to increase the chance of pregnancy. We frequently use other medications to induce ovulation including Femara (letrozole) which, in some cases, has higher pregnancy rates.

Gonadotropin injections

Injecting the gonadotropin hormone can also stimulate ovulation in women. These injections are often combined with IUI. If a male has a low sperm count, gonadotropin injections can help him with that.

IVF

We generally like to try less complex (and expensive) options than IVF to first treat unexplained infertility. IVF does have the best success rates (see below).

When patients opt for IVF as their course of treatment, the procedure can sometimes uncover subtle infertility causes diagnostic tests may have missed, such as egg quality, embryo development or implantation issues.

In many cases of unexplained infertility, TRM recommends intracytoplasmic sperm injection (ICSI) as part of the IVF process. ICSI increases the chance of an IVF pregnancy by injecting a sperm into the area of the egg where fertilization occurs.

Couples experiencing unexplained infertility may also have genetic issues at play. We may recommend IVF patients under go preimplantation genetic screening (PGS) or preimplantation genetic diagnosis before implantation to detect genetic flaws in embryos that can cause implantation failure and miscarriage.

Unexplained infertility treatment success rates

Treatment choices, with the success rate in any given month/cycle following.

• No medical intervention, with patients continuing to try conception on their own: 2 percent.
• Clomid: 4 percent.
• Clomid and IUI: 10 percent.
• Injectable gonadotropins with IUI: in the 20 percent range.
• IVF: over 50 percent.

TRM specialists will walk each patient through treatment options, including the associated probability with each course of treatment.