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Number 8 of 12 posts in 12 days giving you 12 ideas of things to investigate if you are struggling with unexplained infertility.
Unexplained Infertility is not a diagnosis - it is a lack of diagnosis through incomplete investigation. Many causes of unexplained infertility are quite fixable.
One area that is very poorly assessed through the NHS is the state of the vaginal microbiome or the uterine microbiome. I prefer to start by investigating the vaginal microbiome - it is simpler, cheaper and less invasive than a uterine microbiome test, and the two microbiomes are closely linked because the uterine contents flow through the vagina every month.
A vaginal microbiome test is useful for anyone struggling to conceive, but in my opinion it is absolutely vital if there has been any history of thrush, bacterial vaginosis, odd discharges or itches, smelly smells or UTIs.
Infections and imbalance in the vaginal microbiome has been linked to infertility, early loss, late loss, incompetent cervix, pre-eclampsia and pre-term delivery. It's simply not worth overlooking this area (even if these things were in the past and are no longer an issue). Not having symptoms is not a good enough reason not to check this area - around 30% of women with BV have no symptoms, yet the presence of BV increases their risk of implantation failure, early loss and late pregnancy complications.
And no, a vaginal culture through a GP is not as informative and in my experience will often miss critical information as a culture relies on bacteria getting to the petri dish alive so it can grow and then being able to gather enough of it to identify it. The vaginal microbiome tests we use are PCR based tests or NGS based tests, so they are able to identify key players in the vaginal microbiome through DNA signatures whether or not they have perished on route to the lab.
Here is a list of the kind of cases where vaginal microbiome testing would be an essential part of my workup:
a history of vaginal discharge, thrush, BV (even if it was years ago)
frequent or recent use of antibiotics (the protective lactobacillus in the vaginal microbiome are highly susceptible to disruption from antibiotics)
spotting or random bleeding (the presence of blood in the vaginal microbiome can cause it to shift into a more unprotected state)
a history of UTIs
a history of medical interventions such as IUI, IVF, hysteroscopy, colposcopy etc
the presence or history of polyps, fibroids or fibrotic material in the uterus
cervical ectropion
previous childbirth
a partner with genital itch or urinary urgency or who gets up in the night to pee
a history of failed IVF transfers or early loss
a previous pregnancy with a complicated third trimester (small for dates, early rupture of membranes, cervical incompetence etc).
In my opinion, because a disordered vaginal microbiome raises the risks of loss in the first trimester and raises the risk of complications in the third trimester, a vaginal microbiome should be part of any fertility work up. But if you answered yes to any of the above, I strongly recommend you consider checking the vaginal microbiome as part of your pre-conception planning.
I work with a handful of tests - mainly Invivo Healthcare's Vaginal Ecologix and ScreenMe's Vaginal Microbiome, bacteria, yeasts & trichomonas. There are some other tests on the market, but these are the tests I know and like. As a @FertilitySupport Trained acupuncturist, we have had extensive training in microbiome testing. In some of my trickier cases this year, the information obtained has been game-changing!
Reading List
Vitale SG, Ferrari F, Ciebiera M, Zgliczyńska M, Rapisarda AMC, Vecchio GM, Pino A, Angelico G, Knafel A, Riemma G, et al. The Role of Genital Tract Microbiome in Fertility: A Systematic Review. International Journal of Molecular Sciences. 2022; 23(1):180.
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