What if there was a simple explanation for your "unexplained infertility?"
"Everything looks fine."
"You're perfectly healthy and should be able to conceive."
"Just relax and it will happen."
"There's no reason for your infertility so we need to start you on meds."
"The only treatment for unexplained infertility is IVF."
These are some of the statements my patients tell me they heard after seeking help for their inability to conceive. And then there is my favorite - "You need to start prepping for IVF TODAY. Set your ego aside if you want a baby." (fun fact - she got pregnant naturally two weeks later!)
Unexplained Infertility is one of the most frustrating "diagnosis" (or really lack of a diagnosis) that my patients receive. 20-30% of all infertility cases are considered a mystery or unexplained - meaning that all of the extensive hormone testing, anatomy reviews, sperm analysis and other fertility screens have come up clear and normal.
But what if there actually was an explanation for your unexplained infertility? An imbalance just too subtle to show up on paper, but once discovered and treated could lead to a healthy pregnancy.
Just because traditional tests are not able to identify a cause of your infertility does not mean it is unexplainable. And it does not mean you can't get pregnant on your own.
Let me back up.
Conception requires a very delicate interplay of hormones, reproductive organs, nutrients and timing. While your old sex ed class made it seem like a very straightforward process ("Have sex anytime, anywhere and BOOM pregnant!"), it's actually pretty complicated and quite a lot can go wrong during the process at any stage. And yes, while some couples can very easily become pregnant without much thought or planning, others have to work at it.
Infertility is a symptom. Not a disease.
I think of unexplained infertility like a 1000 piece puzzle with missing pieces. Each missing piece is a very subtle imbalance or let's say "micro-cause" of infertility. If one or two of those pieces are missing, you can still put the puzzle together and see the final product. But if a bunch of pieces are missing, say 5, 10, 20 then that starts to get more and more difficult to put together.
Similarly with these "micro-imbalances" leading to unexplained infertility. If a couple just has one or two (and pretty much everyone does), that probably won't stand in the way of a successful pregnancy. But when these subtle imbalances cumulatively add up, we enter the infertility zone. And yes, there is a treatment for each of these, and I often see women fall pregnant after correcting their imbalances.
So what are these subtle imbalances that might lead to unexplained infertility? Here's a list of the most common issues I see in my fertility nutrition practice - do one or more of these sound like you?
1. Nutrient Deficiencies.
We tend to think that if we're eating a generally healthy diet, exercising and taking a prenatal that vitamin and mineral deficiencies aren't something to worry about. This couldn't be farther from the truth. Some nutrients are harder to get - like Vitamin D which mainly comes from sun exposure or a mineral like magnesium or selenium that is dependent on how the food is grown and doesn't show up in significant quantities in multivitamins. Some medications deplete your stores of nutrients - like birth control pills and B vitamins and zinc, or metformin and Folate. And there are other occasions where you may be eating a healthy diet but you're having trouble absorbing or using your vitamin or mineral - if you have chronic GI symptoms this may be the case - Vitamin B12 and Iron tend to be sensitive to absorption issues.
What to do: eat a nutritionally diverse fertility diet, work on your gut health to make sure you're absorbing what you're eating (and get help with this if you're not sure what to do), check out this handy chart for a list of medications and OTC drugs that steal your body's nutrient stores and get tested for some basic micronutrient levels like Vitamin D, Folate, B12, Magnesium and Iron.
2. Hormone Imbalances.
I know, I know. You had your hormone levels tested already and they were fine. But the amount that is in your blood isn't always reflective of the amount of active hormone reaching your cells. In other words - your labs could be completely normal but your hormones could still be off in a more mild way, causing symptoms (trouble becoming pregnant being one of those symptoms).
The most common I see are low progesterone and/ or high estrogen. If you have symptoms of short cycles or luteal phases, cyclical headaches or recurrent miscarriages - your progesterone may need some help. Likewise, if you have a diagnosis of PCOS, endometriosis or fibroids, you have heavy painful periods or bad PMS and a lot of difficulties maintaining a healthy weight, your estrogen may be on the high side.
What to do: Luckily there is plenty you can do to balance out hormones that are mildly off balance with nutrition and supplements. Working with me 1:1 includes a comprehensive hormone assessment.
3. Sub-par Swimmers.
This is probably THE most overlooked contributor to unexplained infertility, and the one that gets me all riled up. The story goes like this - future mama gets hormones and anatomy checked out and all looks normal. Then future papa gets his sperm analyzed and this also comes back clear. Future mama keeps changing her diet, looking for answers and digging deeper to find out why can't I get pregnant if everything is fine? While future papa's work is done and we all assume that piece of the puzzle needs no further investigation.
That literally couldn't be further from the truth. In fact, one recent study identified sperm DNA damage as the cause of 80% of unexplained infertility cases. EIGHTY PERCENT (!!!!). The basic semen analysis usually only looks at quantity and motility and doesn't assess enough on quality. There is often quite a bit of DNA damage on a micro level that isn't seen on these more macro level tests. Damaged sperm = significantly reduced odds at conceiving, as well as higher miscarriage rates.
What to do: your guy should be on a heavy antioxidant diet with a tonnnnnn of brightly colored fruits and veggies. Sperm are delicate little flowers. Millions of them are made daily, and are very very susceptible to damage from inflammation and free radicals. Upping the antioxidants are great for both of you (and everyone in general) but is of particular importance for the male side of couples TTC.
4. Low Grade Inflammation.
This one can be a bit abstract. A number of different conditions or scenarios can trigger a cascade of inflammation inside of your body, activating your immune system. If your body is constantly fighting with itself, fewer resources are available for "optional" systems like fertility.
The more obvious signs of chronic inflammation related to difficulty becoming pregnant are a diagnosis of an autoimmune condition, IBS, arthritis or other inflammatory condition like PCOS or endometriosis. Less directly you can also have an issue with inflammation if you have any chronic GI symptom (see below), skin issues like rosacea or eczema, chronic sinusitis, recurrent vaginal infections or lots of water retention.
What to do: following an anti-inflammatory diet, removing things like sugar and refined grains and eating more omega-3 fats and vegetables is step number 1. If you are still feeling the effects of inflammation, keeping a food diary and working with a registered dietitian will help you identify foods that you have issues with, as this can vary pretty significantly from person to person.
5. Trouble with Digestion.
Digestion and chronic GI symptoms can impact fertility in a few ways. First, remember how we need a nutrient dense diet for increasing our pregnancy chances? If you constantly have diarrhea or loose stool, if you're constipated all the time or very gassy, or a combination of all of these - odds are you are not absorbing all of the wonderful vitamins and minerals in your meals. This will set the stage for one or more nutrient deficiencies. Minerals like iron and zinc, and B vitamins like folate and B12 tend to be at a high risk for malabsorption. And all of these deficiencies on their own can cause a diagnosis of unexplained infertility.
Second - chronic digestion trouble can be either a cause or a syptom of low grade inflammation - so check out point #4 above.
Lastly, there are quite a few studies that have linked the makeup of your gut "good" bacteria and your chances of pregnancy. You can have GI symptoms because of a bacteria imbalance, OR you can have a bacteria imbalance because of your GI symptoms or diet. It's a bit of a chicken-egg situation and we don't always know which came fist. But for the most part this is all simple to treat.
What to do: Anyone with ongoing digestion trouble should start with a gluten and dairy free diet. For at least a month. There are also supplements and more functional foods for helping heal digestion problems, depending on what the main symptoms are. Probiotics and digestive enzymes are helpful places to start. Healing your gut can go a long way as a treatment for unexplained infertility. I find that a lot of my clients having trouble falling pregnant have some kind of GI issue.
6. Toxic Buildup.
The word "detox" is controversial in the medical and health community. While it's not that everyone needs to go on an intense "fertility detox" or "fertility cleanse" - we have a lot of evidence that there are many many chemicals we are exposed to daily that can interfere with our hormones. Things like BPA, pesticides, parabens and dioxins all can lead to challenges trying to become pregnant, and be a cause of unexplained infertility.
Everyone has exposure to these, even if you try to completely avoid hormone disrupting chemicals, some will still show up in your body. I'll argue that every person, man or woman needs to avoid these for their health - but signs you especially need to consider this are if you are suffering from any kind of "estrogen dominant" condition (bad PMS, difficulty losing weight, heavy, painful periods, fibroids, PCOS or endometriosis), your digestion is compromised or you take a lot of OTC or Rx medications.
What to do: Avoid these hormone-disrupting chemicals as much as you can. Eat organic as much as your budget allows, and check out your house and beauty products on EWG.org for their chemical score. Fix your gut (see above!) and support your liver's innate detox ability with cruciferous vegetables like cabbage, cauliflower, and broccoli.
We often underestimate just how much stress can have an impact on our bodies. But any kind of constant, ever-present stress can very significantly alter our hormones. When the stress hormone cortisol is always high, progesterone levels and thyroid levels can drop in women and testosterone in men can be impacted as well. In fact, in a recent study on stress and pregnancy rates the researchers found that high levels of self-perceived stress around the time of ovulation reduced chances of pregnancy by 40%. Obviously that's huge.
Everyone has stress, so this is not to say that you can't have any of it in your life in order to conceive. But when stress is big and constant, or we're having a lot of fatigue, anxiety and/ or insomnia along with it, it's time to address it.
What to do: While quitting your job, becoming independently wealthy and moving to the beach would certainly reduce stress levels, there are some more reasonable ways to work with your stress here. First, sleep. 7.5 to 9 hours per night is where everyone needs to be. Period. Not sleeping enough is one of the most significant physical stressors of modern day. Second, working on a mindfulness practice to reduce the impact daily stress has on your health and hormones. Meditation, journaling, restorative yoga, even just unplugging and being out in nature all can lower your cortisol if done regularly. Pick whichever seems like the best fit and committ to a daily practice.
8. Your DNA.
It's not that fertility struggles are genetic (although to a certain extent things like PCOS does tend to run in families). What I'm talking about here is a common gene variant that affects as much as 25% of the population. It's called a methylfolate reductase mutation. MTHFR mutation for short. (No, it's not what you're thinking).
This can get a bit complicated, but essentially if you have this gene mutation your body has a hard time converting synthetic folic acid to the active form it needs called methylfolate. You've heard of folate and its role in early pregnancy and preventing neural tube defects, and we also need it to convert something called homocysteine into a really powerful antioxidant. So, having this gene mutation sets us up for a folate deficiency and make it more difficult to detox and combat free radical damage. All of these things independently can lead to trouble conceiving and research is pointing to a role of MTHFR mutation and recurrent miscarriages.
What to do: Take a look at your prenatal vitamin to see if it has the synthetic "folic acid" form or the active 5-methylfolate. Switch to a brand with the active form if not. Get more natural folate from foods like leafy greens, citrus and beans and less from fortified food sources like breads and cereals. And get tested! This should be a simple test that your primary or OBGYN can run, along with checking folate, B12 and homocysteine levels. If any of these results are abnormal, working with a dietitian or functional medicine doctor is your best bet for a targeted plan.