The short version
- Unexplained infertility doesn’t mean that there is no reason for it.
- It usually means that the wrong tests were run, the right tests were run but the results were not interpreted correctly, or something has simply been overlooked or ignored.
- In my experience, long term unexplained infertility is rarely one dramatic thing – it is usually two or three fairly ordinary things that haven’t been taken into consideration.
You have been trying for a long time.
You have had the tests. You have sat in the appointments. And at the end of it, someone told you there was nothing wrong – it’s just one of those things. It’s ‘unexplained infertility’.
If you are anything like the people who come to me, you left that appointment feeling worse rather than better.
“We can’t find anything” isn’t an answer. It’s the absence of one.
And I love finding answers.
What “unexplained” actually means
I don’t accept unexplained infertility as a final diagnosis.
If you have a diagnosis of unexplained infertility, it means that, within the constraints of your existing fertility support team, they have run out of ideas.
Unexplained infertility isn’t a diagnosis. Understanding that matters enormously. A diagnosis would be a verdict. Recognising that unexplained infertility is not a diagnosis means that you see it as a starting point.
I am not trying to be critical of your existing fertility support team. Nobody is being negligent here. A GP works within a defined list of tests they are permitted to request. An IVF clinic assesses whether you are a suitable candidate for IVF, which is a narrower question than why aren’t you conceiving – I’ve written separately about why a Fertility Assessment isn’t really an assessment of your fertility. Both are doing the job in front of them. It just isn’t the whole job.
In my opinion, only looking at fertility through a medical lens is too one dimensional. Fertility can be nurtured through holistic support – diet, acupuncture etc. And you may have a holistic fertility support practitioner – maybe a nutritionist, an acupuncturist, a reflexologist – they may be excellent fertility practitioners, but they may not have the training or knowledge needed to work out why you are not conceiving (far too many holistic fertility practitioners also don’t pay enough attention to male fertility, to microbiome investigations or underlying immune system dysfunction).
“But all my results were normal”
If I had a pound for every time I’ve heard this.
When everything comes back looking normal, there are really only a few explanations – and it’s worth knowing which one you’re dealing with.
They didn’t run the right test. This is the most common one by a distance. Many of the investigations that solve the cases I work with sit outside what a GP is allowed to request or what a clinic routinely runs.
Take the standard GP vaginal swab. It’s a culture – it grows what arrives at the lab alive. But several of the organisms most consistently associated with infertility and early loss are anaerobes. They don’t survive the journey to the lab, and they don’t grow reliably in lab conditions. A clear culture doesn’t mean there’s nothing there. It means nothing was detected by a method that was never designed to find it.
It’s worth saying what I’m actually looking for when I run microbiome tests, because it isn’t quite what people expect. People often assume I’m hunting for STIs or a raging infection. More often than not, what I find is dysbiosis – a microbial community that has shifted, with inflammatory bacteria making up more of it than they should. That’s a subtler picture than an infection, but it has a strong bearing on fertility from both an egg and uterus perspective and a sperm perspective.
Thyroid is another. Being told “your thyroid is fine” usually means TSH was checked, and possibly Free T4. It rarely means anyone looked at Free T3, and it almost never means anyone looked at the thyroid antibodies – which a GP generally can’t request anyway. You can have entirely normal looking thyroid tests and still have raised thyroid antibodies, and it’s the antibodies that matter when it comes to recurrent early loss.
They ran the right test, but read it against the wrong yardstick. Here’s the thing about normal: it is a much wider range than optimal. A result can sit comfortably inside the reference range and still be nowhere near where you’d want it for conception. Reference ranges are built to flag disease, not to describe the conditions in which a pregnancy is most likely to establish itself and hold.
There was something to see, and nobody recognised its significance. A number sitting just inside the “normal” range. A comment in the margin of a report. A symptom that didn’t seem relevant. A medication that impacts sperm DNA fragmentation. Clues get overlooked – not because anyone was careless, but because you only notice things if you believe they are significant. And sometimes the devil is in the detail: it’s in the patterns across your results, your symptoms and your history, rather than in any single figure.
Or – occasionally – they really have looked at everything, and there is genuinely nothing to find.
That last one happens. But in my experience it is incredibly unusual. When we can’t pinpoint the issue, it’s rarely because I’ve run out of ideas, it is more likely to be because the tests, investigations or solutions would be too expensive.
Essentially, unexplained infertility is much more likely to be undiagnosed infertility.
Who I see, and why that shapes what I find
Before I go further, I should be straight with you about something, because it affects everything else on this site.
The people who find me have usually been trying for years. Many have been through IVF, often more than once. A lot of them arrive precisely because something didn’t add up and nobody could tell them what, and they were tired of being told to just try IVF again, or not convinced that they really needed to move to donor eggs. They come to me wanting me to figure this out – willing to run the tests, gather the data, and play an active role in finding a solution.
As such, I work with quite a filtered group. They really want to figure this stuff out. We dig in, we run the tests. I’m not going to greenlight someone into IVF without trying to work out why they need it. If I can figure out what’s going on, I have a chance to make a difference. So when I say there is rarely nothing to find, I’m describing what I see in my clinic, not making a claim about everyone who is struggling to conceive.
But it also means I see things that get missed over and over again. That’s not a coincidence. It’s what happens when you spend your working life looking at the cases where the usual route didn’t work.
And if you come to me after an unsuccessful IVF cycle wanting ‘a bit of fertility acupuncture’ to prepare for the next one, unwilling to look at what went wrong the first time, I will gently turn you away. Nothing makes me more uncomfortable than watching someone go through the heartbreak of IVF when they haven’t properly looked at the basics.
Is it really unexplained?
At heart, I’m an acupuncturist, so I see health through that lens. I know that for optimum fertility we need to take a wide look at many different aspects of health – so when someone is struggling with unexplained infertility, these are some of the first things to pay attention to.
Is it unexplained if –
- your menstrual cycle is a mess? Painful, flooding, irregular, spotting for days beforehand? A cycle tells you a great deal and it’s the first thing I look at.
- your digestion is a mess? IBS, bloating, constipation, loose stool – all of it bears on how well you absorb the nutrients that egg and sperm development depend on.
- your sleep is broken? Sleep affects both of you, and it’s one of the more fixable things on this list.
- your iron stores were emptied by years of heavy periods, and nobody checked your ferritin?
- nobody has looked properly at your thyroid antibodies?
- that odd discharge you mentioned once was never properly investigated?
And – because this is the one that gets skipped most reliably of all –
- is it unexplained if nobody has looked into why his semen analysis wasn’t quite right?
- if nobody picked up that his testicles ache at the end of the day?
- if nobody asked what he does for a living, or whether he has a bath every night, or whether he’s partial to a sauna or a hot tub?
I want to be clear that I’m not describing exotic stuff here. Most of this is ordinary. It’s just nobody’s job to go looking for it. And much of it is relatively simple to address – but if you’re putting the effort in and your cycle is still awful, your digestion is still a mess and your sleep is still broken, then I need to take a closer look to see if there’s an underlying reason why.
What I actually do about it
I go through everything with a fine-tooth comb – your history, your symptoms, every test result and scan report you’ve collected along the way, and the same for your partner. I’m looking for the things that were recorded and passed over, the questions nobody thought to ask, and the tests that should have been run and weren’t.
Sometimes what I find is straightforward and the fix is simple. Sometimes it takes a team – I work alongside a visceral osteopath, functional nutritionists, microbiome specialists, and urologists with real expertise in male fertility investigations. Occasionally we end up a long way off the usual path, in the realms of long covid, reactivated viruses and Lyme disease.
But most cases are more ordinary than people fear by the time they reach me. Far more often, it’s two or three unremarkable things that were sitting there, unexamined, and together they were enough.
I can’t promise I’ll find an answer for you. Nobody honest can. What I can tell you is that “unexplained” is very rarely the end of the enquiry – it’s usually just where the last enquiry stopped.
If you’ve been told your infertility is unexplained and you’d like someone to look at the whole picture properly, that’s what a 360 Fertility Review is for.