Episode 162: Fertility 101: Unexplained Infertility

The Fertility 101 Series, because there’s no shortage of daunting terms to keep your mind running, is a quick and dirty breakdown on a specific topic with insights from a fertility expert.

In today’s episode, Dr. Callum Potts breaks down the unexplained infertility diagnosis. He walks us through the four factors of fertility, how they work collectively to create a natural pregnancy, and why these four factors could test normally without positive results. Dr. Pott’s discusses treatment options such as IUI and IVF, and how someone may decide on which path to take.

While an unexplained infertility diagnosis is frustrating, Dr. Potts emphasizes that treatment options are not limited and testing normal is a positive thing.

Guest: Dr. Callum Potts, CCRM Miami

Host: Dan Bulger, Progyny

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Here are some highlights from this episode:

Four Fertility Factors

02:47 – 05:09

Dr. Callum Potts: We kind of think about four big things that we need to conceive a pregnancy. One is sperm. And so, an evaluation of infertility always involves the male partner, if one is present, looking at a semen analysis to look at various parameters of sperm function, and making sure that those are within normal ranges. We look at various factors involved in how an egg is released, we can look at factors involved in ovarian reserve, which is basically the number of eggs that exists in ovaries, there are blood tests and ultrasounds that we can do to look at that ovarian reserve number. And there are also a range of hormonal tests that we can do to look at how an egg is being released how the brain and the ovaries are talking to each other. And making sure that reproductive access is intact. And so there are hormones from the brain like follicle stimulating hormone or FSH, luteinizing hormone or LH, thyroid stimulating hormone or TSH, prolactin, there are other hormones from the ovaries themselves like estrogen and progesterone that we can interrogate and look at to see if there’s a specific hormonal reason why an egg may not be being released in an adequate fashion. Egg and sperm meet in the fallopian tube. So, the third thing that we investigate is the fallopian tubes with an imaging study just to show that they are open or not. Once egg and sperm meet, they become an embryo in that fallopian tube, and they travel down into the uterine cavity to implant to become a pregnancy. So, the fourth and last thing that we can investigate is that uterine cavity. Many patients’ tests will come back to normal. And that really gets us to that, that unexplained infertility diagnosis.

Three Paths to Parenthood

08:43 – 12:05

Dr. Callum Potts: The first option is always you can do nothing, you can kind of expectantly manage the process, there is an approximately three percent chance per month of achieving a pregnancy. So, it’s not high, but it’s not nothing. The first or the kind of least invasive treatment option that we could recommend would be some combination of oral ovulation induction medications. So, these are medications like Clomid or Letrozole as well as an intrauterine insemination. So, if we can do this IUI procedure and bring in a million purified and activated sperm into the uterus to meet not one egg, but maybe two or three eggs, that combination of factors can help to increase the chance of pregnancy to somewhere between eight and twelve percent each month. So, it’s not super high. But it certainly gives you a substantial increase over just trying naturally at that point. And then the other big treatment option that we have is IVF. And that’s the most complicated, it’s the most expensive, it’s certainly the most likely to be a successful treatment option.

Dan Bulger: It’s a person-by-person decision. And there are more factors at play than just medical concerns, given the cost of these treatments. But I asked Dr. Potts, if there were any factors that could help people in choosing what path might be right for them.

Two Functions of IVF

12:55 – 16:59

Dr. Callum Potts: For couples that are 38 years or older, I think there’s also a reasonable recommendation to go straight to IVF. The likelihood of having a live birth and kind of the accelerated chance of having a live birth really becomes more important in the slightly older age groups just to really get to the endpoints as quickly as we can. That being said, you know, it’s not wrong to choose either option, you know, outside of those recommendations. So, for example, my wife and I have unexplained infertility or had unexplained infertility. Our goals were to try and achieve pregnancy as quickly as possible. IVF is certainly the most likely treatment option to get to that point as quickly as possible. So, we chose IVF.

Dan Bulger: So, IVF would have the highest likelihood of leading to a baby quicker than the other options. And for those who are choosing to move to IVF, there’s also an added factor at play to there is a diagnostic element to IVF. I don’t mean that people should do IVF to diagnose their problem. The point of IVF is not diagnostic, but an IVF cycle can actually answer a lot of these unexplained questions.

Dr. Callum Potts: You know, IVF is a great way for us to learn about some of those factors that we can’t test for ahead of time. When we retrieved the eggs from the body, we get a chance to look at them under the microscope.

Dan Bulger: So unexplained infertility isn’t the end of the road. I think of it as bad branding. You never want to hear your doctor say they diagnosed you and also say it’s unexplained at the same time. But semantics aside, an unexplained infertility diagnosis can be seen as an opportunity.