Infertility is not a disease, yet it is usually approached medically as if it were one. We, as physicians, are trained to approach all bodily malfunctions in such a way that an assortment of tests are used to make a diagnosis. More obscure illnesses require more comprehensive and elaborate testing. Once testing suggests a diagnosis, treatment is based solely upon that diagnosis. if the diagnosis is correct a patient will then be cured by the appropriate treatment.

This approach works well with an illness, such as a kidney infection, but not necessarily with infertility. For example, when a patient presents with painful urination, urine tests may identify the presence of bacteria of a certain type along with information regarding the most effective antibiotics. An antibiotic is given to the patient who will usually then recover. In this case, treatment is diagnosis driven.

In the case of infertility, the process that leads to a successful conception is really too complex to dissect diagnostically. There are too many steps prior to, and after, fertilization, that must be in proper alignment for the process to work. I often visualize conception to be like a long line of dominoes. When the system works, all the dominoes fall over, in their turn, until the last one tumbles. Only one domino need be slightly out of line in order to make the system fail, since the process stops at a point prior to its successful completion. Successful conception requires many complex biological steps to complete the process. If one step does not work, the whole system breaks down and does not reach the end point of pregnancy. Unfortunately, most often It is impossible to tell exactly at which point the process fails.

To make matters even more complex, many of the blockages to conception occur on a cellular or molecular level. In fact, even after successful fertilization, most embryos, even those that appear to be perfectly formed, have genetic molecular defects the ultimate cause of implantation failure. Only 25% (or less) of embryos become clinical pregnancies.. The 75% (or more) which do not survive, will have had some type of genetic or chromosomal abnormality.

The reality is that there are only three diagnostic tests, which if unequivocally abnormal, will lead to an accurate diagnosis of sterility. If a test of tubal patency shows that both tubes are blocked, conception is impossible. If tests of ovulation show an absence of egg production, conception will not occur. Finally, if the semen analysis is consistently devoid of motile spermatozoa, pregnancy will not occur. If, however, one tube is open, ovulation occurs on a infrequent basis, or the semen analyses reveal poor specimens, pregnancy frequently can, and does, occur. In these instances, even the most basic of diagnostic tests cannot accurately predict whether conception is possible. Therefore, it is possible to accurately diagnose absolute sterility, but very difficult to establish a causative factor in subfertility.

If a couple who has not conceived in a period of time appropriate for their age is determined to be potentially fertile, there are four possible areas in which factors could reside which would prevent conception.

1. Defective egg production, despite normal ovulation.

2. Open, but nonfunctioning Fallopian tubes.

3. Factors that block fertilization in the body.

4. Biologically nonfunctioning sperm despite a normal semen analysis.

Unfortunately, no tests exist to evaluate potential problems in the above areas. Therefore, infertile couples may benefit more by working toward finding therapy to either augment the natural process or conception or bypasses the problem area, rather than spending too much time on diagnostic testing.