There may be several reasons why the fuzzy diagnosis of unexplained infertility is so widely given. One possibility is that there is no obvious cause for a couple's infertility and that their problem may be the result of multiple minor aberrations in how their respective reproductive systems cooperate. After all, the successful establishment of pregnancy is a highly complex process, and at least on a theoretical level, one can assume circumstances where male and female fertility are each affected only to such a mild degree that standard diagnostic test results would still be considered within normal range. Yet, together, the reduction in the couple's combined fertility potential may be large enough to cause infertility.
Whether such a circumstance indeed exists is highly questionable, however. Moreover, even if it did exist, it would be incumbent upon us to improve the sensitivity of our diagnostic testing, so that testing procedures will be able to detect even subtle and multifactorial abnormalities in the reproductive processes which can lead to infertility.
The diagnosis of unexplained infertility can be only as good (or bad) as the diagnostic workup that has been performed.
Any such improvement in diagnostic abilities would then eliminate the need for a diagnosis of unexplained infertility, which brings us to the main rationale of our argument against the continuous use of this terminology: Since the diagnosis of unexplained infertility is a diagnosis of exclusion, it will be only as good (or bad) as the diagnostic workup that has been performed.
Another way of saying this is that the more comprehensively and the more accurately the diagnostic workup is performed, the more likely will a true cause for a couple's infertility be detected and the less likely will they end up with a diagnosis of unexplained infertility. The opposite is also true: the shoddier a diagnostic evaluation, the more likely will it end up with a diagnosis of unexplained infertility.
This, of course, creates a rather peculiar incentive structure: the poorer the medical care, the more likely a couple will end up with a diagnosis of unexplained infertility: exactly the opposite of what one would like to see with good medical practice in which good care should be rewarded by better diagnostic accuracy.
Physicians and their professional organizations disagree on what constitutes a complete infertility evaluation. The hypothetical conclusion that a couple suffers from unexplained infertility will, therefore, greatly vary between practitioners, and what is considered unexplained infertility in one practice may have a very specific diagnosis in another. Indeed, at CHR we have become convinced that the four very specific conditions are frequently overlooked and misdiagnosed as unexplained infertility. We have reached this conclusion not only based on observations in our own patients but also from a careful analysis of the medical literature. And, while the brief summary here does not allow us to offer the necessary detail of our literature review, we encourage our readers, who are interested in more detail, to contact us and we will gladly provide you with a more detailed manuscript.
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Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.