I Want Answers

We all want explanations in life and it is human nature to seek out the answers to our questions. Unfortunately, life is not simple and sometimes there are questions that we cannot answer and outcomes that we cannot understand.

Although we can often determine the root cause of infertility, sometimes we are at a loss to explain why a couple is not conceiving. The problem is that in such cases we are forced into treating empirically and hoping for the best. IVF can offer some insight into these cases but sometimes it is a hard concept to get across to the patient:

DrG: I have good news…all of your tests are normal.

Couple: That is great news…we were so worried that you were going to tell us we needed IVF!

DrG: Uh….

Couple: So what are you going to recommend?

DrG: IVF.

Couple: Uh…..

IVF is not the only option in such cases but it is the only option that provides clinical information even in the face of a negative pregnancy test.

So here is the “Question of the Day” on this hot and humid Sat AM in Washington, DC.


14. Can infertility be unexplained?


Although the etiology (underlying source) of infertility in many couples can be elucidated by various forms of testing, including careful physical examination and history, there still remains a sizable percentage of couples in whom no obvious cause of infertility can be identified. Some studies estimate that approximately 10% to 20% of patients fall into this category. However, “unexplained infertility” is not necessarily equivalent to “untreatable infertility.” If a couple has prolonged, unexplained infertility with no previous pregnancies, then a number of etiologies are possible. If the woman is having normal, regular menstrual cycles, it is likely that an egg is growing and being released in an appropriate fashion. If pregnancy has never occurred, however, we cannot be sure that the woman’s fallopian tubes are able to catch the egg or that her male partner’s sperm are able to swim through the cervix and uterus and find the egg in the fallopian tube (where fertilization normally occurs). If the sperm is able to reach the egg, the absence of a previous pregnancy raises the question as to whether fertilization can, in fact, occur. The scope of this problem is made clear when we look at the fertilization results for patients who undergo IVF. Typically the rate of failed fertilization with IVF is approximately 2%, but this rate increases dramatically—to approximately 20%—in couples who have prolonged infertility with no previous pregnancies. Failed fertilization can be the result of a problem with either the sperm or the egg, or both. Since the introduction of intracytoplasmic sperm injection (ICSI; described later in this book), however, the specific causes of fertilization failure are not as important as the fact that we have a means to avoid this unfortunate outcome in most cases. One of the most significant developments in the treatment of infertile couples has been the move away from extensive diagnostic testing and toward a more rapid recommendation to undergo IVF. We often recommend that patients with prolonged unexplained infertility consider IVF with ICSI, as this combination has both diagnostic and therapeutic benefits.