By Dr. Shawna Darou, ND
Unexplained infertility is one of the most difficult diagnoses to receive because if provides little direction about next steps. I prefer to think of it as “not yet diagnosed.” This checklist is designed to be a short-cut to help you to understand the possible causes of your fertility struggles. If we can understand a possible cause, it makes it simpler to get the right help and support. Please keep in mind, that this questionnaire does not substitute the advice of a physician.
Under each category, please check off the answers that apply. You may find several conditions this questionnaire that apply to you. Remember, the key with unexplained infertility is to understand the ‘why’. Here is a list of the most common causes of “Unexplained Infertility” and how to recognize them.
- Have your periods been painful since your teenage years?
- Do you need to take significant amounts of pain medication (over-the-counter or prescription) to manage your cramps? This means taking more than 2 regular strength ibuprofen during a period.
- Does your cramping start the week prior to your period?
- Do you have diarrhea or loose stool with menstruation?
- Is your ovulation time painful with cramps or sharp pains?
- Do you have painful intercourse?
- Do you have a mother or sister who has been diagnosed with endometriosis?
If you answered yes to 3 or more of these questions, you may have endometriosis. Did you know that endometriosis is the most common cause of unexplained infertility?
- Are you over age 38?
- Do you have secondary infertility? This means that you successfully had one or more pregnancies, but are currently struggling to conceive.
- Are your menstrual cycles getting closer together? Meaning is your cycle length reducing from 28-30 days to 25-26 days?
- Are your periods much heavier at the start and then tapering off very quickly compared to before?
- Do you have a mother or sister who had menopause before the age of 46?
- Have you been a poor responder to fertility medications or IVF?
- Have you had frequent X-rays in your life, or frequent air travel (more than 8 flights per year), or other sources of radiation exposure?
If you have answered yes to two or more of these questions, you may be dealing with issues with your egg quality, even if your hormones are testing in the normal range.
Luteal Phase Defect / Low Progesterone
- Do you have premenstrual spotting? Meaning does your period start very light for one or more days before you have real / heavy flow?
- Are your menstrual cycles short (less than 26 days)? This means counting from day 1 of your period through to the day before your next period begins.
- Do you have a short luteal phase? This means that from the date of ovulation until the first day of your next period is less than 10 days.
- Are you over age 38?
- Is your progesterone level on day 21-23 of your cycle less than 35 nmol/L (less than 11 ng/mL)?
- Have you been through a long period of high stress?
If you have answered yes to any of these questions, low progesterone may be the cause of your unexplained infertility.
Polycystic Ovarian Syndrome
- Are your periods irregular?
- Do you have acne? (especially if you have had skin troubles since puberty)
- Do you have extra body or facial hair growth that is not typical for your ancestry? (especially on the chin, around the nipples and lower abdomen)
- Do you tend to carry weight around your central abdomen?
- Does anyone in your family have PCOS?
- Do you have relatives (mother, father, aunts, uncles, grandparents, siblings) with non-insulin dependent (type 2) diabetes?
- Do you have hair loss around the hairline, or from the crown of your head?
- Have you been diagnosed with ovarian cysts?
If you have answered yes to two or more of these questions, you may have polycystic ovarian syndrome. Please note that not all women have the classical over-weight presentation of this condition. If you are thin and have irregular periods, this is still a possibility that can be accurately diagnosed with the correct blood work and a pelvic ultrasound.
Non-classic Adrenal Hyperplasia
- Do you have signs of high testosterone: acne, head-hair thinning or extra body hair growth?
- Are your periods irregular?
- Do you have cysts on your ovaries?
- Did you start menstruating at 10 years of age or younger?
- Are you shorter than the rest of your family?
Non-classic adrenal hyperplasia is the big mimicker of PCOS. If you have many PCOS symptoms, but are normal weight and answered yes to two or more of the questions above, blood tests can confirm whether you may have non-classic adrenal hyperplasia. This condition is more common in certain groups: Ashkenazi Jews, Hispanics and Italians.
- Do you have a long menstrual cycle (more than 31 days?)
- Are you overweight or have difficulty losing weight?
- Are you often tired?
- Do you have often have constipation?
- Do you usually feel cold or get chills that are hard to warm up from?
- Do you have very dry skin?
- Do you have brain fog or difficulty concentrating?
If you have answered yes to three or more of these questions, you may have a sluggish thyroid or hypothyroidism. A full blood thyroid panel is recommended to confirm, including testing for thyroid antibodies.
Thin Uterine Lining
- Do you have light or scanty periods?
- On ultrasound have you been told your uterine lining is thin (less than 8mm at ovulation)?
- Do you have light periods, and you have been on oral contraceptives for more than 10 years in the past?
- Have you had more than 2 D&C (dilation and curettage) for miscarriage or abortion, and your periods have been very light since then?
If you answered yes to any of these questions, a thin uterine lining may be the cause of your unexplained infertility. Read more about thin uterine lining here.
- Do you have any type of autoimmune condition: Hashimoto’s thyroiditis, Grave’s disease, rheumatoid arthritis, lupus, Sjogren’s, Crohn’s disease, ulcerative colitis,…
- Does anyone in your family have one of these conditions?
- Do you have or have you in the past had allergies, eczema or asthma?
- Do you have many food intolerances?
- Do you have celiac disease?
- Do you have endometriosis?
If you have answered yes to any of these questions, an over-active immune system may be the cause of your unexplained infertility.
- Do you have signs of low progesterone / luteal phase defect (see above section)?
- Have you been told that your prolactin levels are a little high?
- Would you rate your stress at a level of 6/10 or higher?
- Do you experience frequent anxiety, worry or feelings of overwhelm?
- Have you recently been through a prolonged period of high stress?
- Do you feel ‘tired but wired’, have non-restful sleep, or mid-afternoon fatigue?
- Are you experiencing abdominal weight gain?
- If you are charting your periods with basal body temperature tracking, do you see a ‘saddle pattern’ after ovulation? This means that the temperature rises well after ovulation, but then dips for several days in the middle of the luteal-phase.
If you have answered yes to any of these questions, stress may be affecting your fertility. Stress is a very common cause of fertility struggles as it can affect all of your hormones, and amplify other underlying causes.
- Have you had more than 2 miscarriages?
- Do the following health issues run clearly through your family: early cardiovascular disease (heart attacks before age 60), blood clots, mood disorders especially bipolar, frequent miscarriages, autism, Asperger’s, addiction, schizophrenia,…?
- Do you carry the MTHFR gene mutation?
If you answered yes to any of these questions, methylation defects may be the cause of your unexplained infertility.
- Does your male partner have high stress levels?
- Does your male partner have high alcohol intake (more than 10 drinks per week?)
- Does your male partner use marijuana products more than once per week (and especially daily)?
- Does he have low libido or low testosterone?
- Is he on any medications (including medications for hair growth such as minoxidil and propecia)?
- Is he more than 45 years of age?
- Does he have any autoimmune conditions?
- Has he had a vasectomy reversal?
If you have answered yes to any of these questions, male factors may be affecting your fertility, even if his basic semen analysis testing looks normal.
Cervical Fluid Issues
- Do you have dryness during intercourse or need to use lubricants?
- Is it very difficult to tell when you have ‘egg-white’, slippery mucous around ovulation time?
- Are you prone to frequent yeast infections or bacterial vaginosis?
- Do you regularly take antihistamines for allergies?
- Are you using clomid to help your fertility?
If you have answered yes to any of these questions, cervical mucous issues may be affecting your fertility.
Blocked Fallopian Tubes or other Structural Issues
- Have you ever had a sexually transmitted disease, especially chlamydia or gonorrhea?
- Do you have known or suspected endometriosis?
- Have you had any past abdominal or pelvic surgeries?
- Do you have uterine fibroids?
- Have you been told that your uterus is tipped or tilted?
- Have you been told that you have an unusually shaped uterus? (arcuate or heart shaped, or you have a septum in the uterus)
If you have answered yes to any of these questions, there may be a structural issue that is affecting your fertility.
Over-exercising / Underweight
Please answer the following if you are exercising more than 4x per week, and at a high intensity (for example spin classes, cross-fit, long-distance running, triathlon training):
- Have your periods changed in heaviness or frequency?
- Are your periods irregular?
- If you have had your estrogen level tested, is it low?
- Do you have low body-weight or low body-fat (less than 18%)?
- Do you also have a high-stress life (stressful job / home-life / relationship / family circumstances)?
Please answer the following if you are a thin build:
- Is your BMI less than 19? You can calculate your BMI by dividing your weight in kg by your height in metres squared. (BMI calculator here).
- If you have had your body fat calculated, is it less than 18?
- Are your periods irregular?
- Are your periods lighter than they used to be?
- If you have tested your estrogen, is it low?
If you have answered yes to any of these questions, your weight and or exercise may be contributing to your unexplained infertility.
- Do you have BMI higher than 28? You can calculate your BMI by dividing your weight in kg by your height in metres squared. (BMI calculator here).
- Do you have irregular periods or irregular ovulation?
- If yes, do your periods become more regular by taking metformin?
- Are you pre-diabetic, or do you have insulin resistance?
- Do you have high blood pressure?
- Have you been diagnosed with PCOS?
If you answered yes to two or more of these questions, metabolic syndrome may be affecting your fertility.
I hope this short article has given you some insight into possible causes of unexplained infertility. If you would like to take the next step with assessment or treatment, please book in for an appointment to personalize your approach. Remember that unexplained infertility simply means not yet diagnosed.
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