Unexplained Infertility: When All the Tests Are Normal

Dear Doctor,

My husband and I have been trying to get pregnant for a year and a half. I’ve done all the recommended tests, and everything came back normal. My husband also had a sperm analysis, which was good. Yet, I’m still not pregnant. They’re now telling us it’s unexplained infertility… How is that possible?

Pauline*, 29 years old *name anonymized

Dear Pauline,

Your situation is unfortunately more common than many think. About 10 to 20% of couples facing difficulties conceiving are diagnosed with unexplained infertility—meaning no specific cause can be identified, despite normal test results for both partners.

What Is Meant by Unexplained Infertility?

Infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse. When a couple seeks help for this, several evaluations are typically performed: hormonal testing for the woman, ovulation monitoring, assessment of the fallopian tubes (via hysterosalpingography or sonohysterography), and semen analysis for the man.

If all results come back normal, but pregnancy still doesn’t occur, the diagnosis is unexplained infertility. This can be particularly frustrating, as most people expect to find a clear cause that can be treated.

What Could Be Happening Despite Normal Results?

It’s important to understand that fertility tests assess certain general parameters, but may miss more subtle issues, such as:

• Poor egg quality, which might not show up on standard tests;

• Fertilization or implantation problems that are undetectable with current tools;

• Cervical mucus and sperm interaction issues;

• Immune or inflammatory conditions of the uterine lining;

• Minor sperm abnormalities not revealed in a basic semen analysis.

What Are the Treatment Options?

Management depends on the woman’s age, the duration of infertility, and other personal factors. At 29, you likely still have a good ovarian reserve, which is a positive factor. The options include:

1. Continuing to try naturally for a few more months, especially if infertility is relatively recent (less than 2 years) and cycles are regular;

2. Trying mild ovarian stimulation with intrauterine insemination (IUI) to increase the chances of sperm and egg meeting at the right time;

3. If several IUIs fail or the woman approaches age 35, in vitro fertilization (IVF) may be proposed—even when no clear cause is found.

   
   

Emotional Support Is Key

Unexplained infertility can lead to significant emotional distress. It’s essential to talk about it—as a couple, with your doctor, or even with a counselor specializing in fertility. The uncertainty can be stressful and sometimes lead to feelings of guilt or helplessness.

Are There More Advanced Tests?

In some cases, more in-depth investigations may be offered: endometrial receptivity testing (ERA), diagnostic hysteroscopy, sperm DNA fragmentation testing, or immune testing. These are not done routinely and depend on the individual clinical picture.

In conclusion, unexplained infertility does not mean you have no chance of conceiving. Many couples eventually succeed—sometimes spontaneously, sometimes with a little medical help. The key words are patience and support, because every fertility journey is unique.

Dr. Sandra Yene Amougui

Do you have a question or story to share? Write to me at: info@gyn-yaounde.com.

I may respond in a future blog post.