Unexplained fertility is not a diagnosis. Fertility test checklist.

Dear Lord Winston. I am 40 and a half, my husband is 42. Trying for two and half years to become pregnant. Never been pregnant. I was on Dianette from 17 to 38. I’m on Venlafaxine under psychiatric care, they are all aware of the baby plans. Just had our first IVF at the XXXX after unexplained infertility diagnosis by NHS. Given immune therapy. Sadly, on Friday, my 4 eggs didn’t fertilised with my husband’s sperm. They said they were going to do ICSI, but at the last minute thought IVF would be ok as everything looked good. I agreed to this. Devastated we didn’t even make an embryo, and £13,000 poorer for what feels like nothing, your opinion would be very much valued. Thank you. J

Dear J

I am going to give you what may seem quite a harsh answer and I am ready, of course, to stand by what I say and also to try to help.

Firstly, you refer to ‘unexplained infertility diagnosis’ by the NHS. I have repeatedly tried to explain, on this website and in my various books on infertility, that there is no such thing as a diagnosis of unexplained infertility. This is not a diagnosis, but a failure of diagnosis. So the first thing that any couple faced with the news that they have ‘unexplained infertility’ is to ensure that they really have been thoroughly investigated in order to ascertain the cause of failure to conceive. Only then should IVF be contemplated and then it should be done in a clinic that, in addition to trying to get you pregnant using IVF, is using IVF to see if there is any further information which might throw light on the reason for your failure to conceive.

Here are just a few suggestions for example: In your case, your eggs did not fertilise. Were you given information as to whether this was likely to be due to a sperm problem, or alternatively a problem with your eggs? So – what were your hormone results – in particular estrogen levels in the run up to egg collection? Was there any evidence of a premature LH surge which might have caused your eggs to mature inadequately? How many follicles were there and what size did each reach? And what was the quality of the sperm like? Why were you scheduled to have ICSI in the first place – was there thought to be a sperm problem? Did, for example, the sperm show attachment your eggs? Was the zone penetrated by any of them in any eggs? What was the motility like on the day in question?

Now, even before contemplating IVF, there is a checklist which – in my view – must be completed. These tests must be done to ensure that the infertility is truly unexplained.
1. Did you have regular ultrasound to ensure follicular development and ovulation? Was polycystic ovary syndrome ruled out? What were the physical size of your ovaries?
2. Did you have your FSH, LH, progesterone at least twice before IVF at the right time of the cycle? Was AMH checked? Do you have a thyroid problem? Are you overweight or underweight?
3. Did your husband have sperm function tests in addition to routine sperm counts?
4. Was a postcoital test done to see if sperm were active in your cervix – an under-used but important cheap test in people like yourself? (particularly important in your case seeing as for some reason you were offered ICSI arguing a sperm problem)
5. Did you have a hysterosalpingogram (an x-ray, not an ultrasound) to confirm that that uterus is normal, with a properly formed cavity, and that the tubes are fully open on both sides?
6. Did you have a laparoscopy to confirm that your internal organs are entirely normal? For example, one in four women by the age of 40 will have fibroids which may interfere with conception, and many others may have endometriosis, evidence of inflammation or adhesions.

If all the above tests have been done, and been shown to be normal, there is plenty of evidence from studies in Holland and Belgium (both of which offer excellent infertility services) that your chances of getting pregnant naturally are certainly as good as by having IVF. But in your case you spent £13000 – I am really sorry to emphasise this, because it is quite shocking – and then seemed to have received treatment, part of which, for example, is not based on any serious evidence that it was desirable or necessary. For example, how was it you had immune therapy which has not been shown to be of clear benefit in any randomised controlled trials in women like yourself – the gold standard of assessing any ‘innovative’ treatment.

I am truly sorry to write to you in this negative fashion, but I hope my comments about ‘unexplained infertility’ may lead you to some optimism – not least because in the long term you may be more likely to conceive on your own after a healing process of mind and body, than by further attempts at IVF which are not likely in any woman of your age to offer a major chance of success.

Because I think we should publish your letter anonymously my answer on our website, I have deleted the name of the clinic where you were treated.

My best wishes to you
Robert Winston