After trying to conceive for nearly two years, Jennifer, a then 36-year-old New York journalist, made an appointment at one of the city’s top fertility clinics. When tests of both her and her husband came back normal, doctors gave them a frustrating diagnosis: unexplained infertility. Loosely defined as an inability to get pregnant after a year of trying when both partners’ reproductive organs seem to be functioning normally, it’s a label that, by some estimates, is applied to as many as 30 percent of fertility patients. Because Jennifer, who asked that her last name not be published, was over 35, her doctor recommended Clomid, a pill that stimulates the ovaries to produce more eggs, and intrauterine inseminations (IUIs). When that course failed, treatments were ratcheted up to include injectable drugs, but they didn’t work either. The next step was in vitro fertilization (IVF), which would have required her to inject higher doses of fertility drugs and have eggs harvested from her ovaries. Embryos, created in the lab, would then have been deposited into her uterus. It was at that point that Jennifer put on the brakes. “I said, ‘Wait a minute. Time out,’” she remembers. “Why do I need all of this if they can’t find anything wrong with my body?”
Now, some fertility experts are beginning to ask the same question. Though much about reproduction remains a medical mystery, many “unexplained” infertility cases, they say, can be explained with deeper sleuthing. These doctors contend that physicians should be working harder to pinpoint the reason for a woman’s inability to conceive before starting her on a program like Jennifer’s, one that can be expensive—at $10,000 to $15,000 per cycle, IVF is not covered by the majority of insurance plans—physically stressful and, of course, emotionally fraught.
Among them is Sami S. David, a Manhattan fertility specialist who, in 1983, was part of the first team of doctors to successfully perform IVF in New York. These days David, an assistant clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, no longer does the procedure, preferring instead to serve as what he calls “a medical detective,” searching out the hidden causes of infertility in his patients. It’s a skill, he believes, that has fallen by the wayside at a time when success rates from assisted reproductive technologies like IVF have been on the rise. “When I was starting out, we were taught the basics: Do an overall medical evaluation, perform tests, make a diagnosis, then treat a patient,” he says. “I believe this is still the right way to treat infertility. You need to make a diagnosis before you treat a problem. That’s a step that’s being skipped. Maybe doctors don’t care about making a diagnosis because the attitude is, ‘We can make you pregnant with fertility drugs, no matter what the problem is.’”
Over the years, David says, he’s helped countless couples with so-called unexplained infertility—some of whom have already failed at IUI or IVF—conceive with low-tech remedies. He favors a holistic approach, often working with acupuncturist Jill Blakeway to help patients deal with stress and talking to both partners in depth about every detail of their lifestyles. In the course of such conversations, he says, he’s come across men who were unknowingly damaging their sperm by taking scalding baths every day or by spending hours with a hot laptop perched on their pelvises. “I’m not against IVF. I’m pro-IVF—for the women who need it,” says David. “What I’m against is the fact that, as physicians, we’re not spending enough time speaking to the patients, studying the tests. Many fertility doctors pretty much know before they walk into the exam room what they’re going to recommend: a couple of Clomid cycles, then inseminations, then in vitro.”
The standard fertility workup at most clinics includes hormone-level tests; a hysterosalpingogram (HSG) test to rule out blockages in the fallopian tubes; and a semen analysis to determine sperm count, shape and motility (or swimming ability). David says he often finds overlooked causes of infertility by performing a simple postcoital exam the morning after intercourse to evaluate the quality of a woman’s cervical mucus and to assess whether sperm are alive and moving normally. If the sperm are dead, David says, the vaginal environment might be too acidic, for which he recommends a baking soda douche before intercourse. If the cervical mucus is too thick to allow sperm to swim, he prescribes an over-the-counter cough medicine like Mucinex. “Many of my colleagues don’t do this test because they have all read the same paper that says some people who have a bad [post]coital exam still get pregnant and some people who have good postcoital exams don’t,” he says. “But my question to them is very basic: Is a woman more likely to get pregnant with live sperm inside of her or with dead?”
David also believes that bacteria can cause infertility, a view that some in his field don’t share. Many doctors do cultures of the cervix to check for chlamydia and gonorrhea, but David contends that other bacteria—such as mycoplasma and ureaplasma—can also interfere with conception, whether present in the woman or the man. “Most doctors do cultures of the cervix, but many of them aren’t looking for these more routine bacteria,” he says. “And very rarely do they do cultures of the semen, which I think is crucial. I’ve seen a number of cases of E. coli and staphylococcus in the sperm. You give them antibiotics, and they get pregnant.”