(In)fertility – Everything seems normal, but you’re not getting pregnant?

Receiving a diagnosis of “unexplained infertility” can feel devastating. It’s one of those clinical terms that seems to say everything and yet nothing at all. In practice, it provides no real answers. And all too often, it steals away hope.

So, what can be done?

If you're reading this, there's a strong chance you've heard the phrase: “Everything looks normal, we don’t know why you haven’t conceived yet.” Perhaps you’ve already undergone the usual battery of tests — scans, hormone panels, endless blood work — that ultimately provide no clear answers. What follows is just a cold, clinical term that conceals a devastating truth: unexplained infertility.

It’s not a dead end; it’s an invitation.An invitation to listen to the body more closely, with care and respect.An invitation to look beyond the numbers and charts and remember that each woman is a universe — and every universe deserves to be understood in its true depth.

(In)fertility Unexplained

For many women, this may be one of the hardest sentences to accept. Not because of the word “infertility” — there is fight, hope, action — but because of “unexplained”. How is it possible that, in the 21st century, with all the science and technology available, we can say simply: “We don’t know why you can’t conceive”?

Conventional medicine labels this “unexplained infertility” when, after basic tests in both partners, no obvious reason for conception difficulties is found. This occurs in around 25% of infertility cases in Portugal.

The conventional recommendation after two years of trying — especially if the woman is under 40 — is usually to proceed with assisted reproductive treatments like IVF. However, before reaching that stage, medications such as clomiphene (Clomid) are often suggested, even though some guidelines indicate that it does not improve pregnancy rates in cases of unexplained infertility compared with continued natural attempts.

The truth is that clomiphene, besides not helping many cases, can worsen feelings of frustration and disconnection from one’s own body. I see this repeatedly in women who come to me: they feel exhausted, not just physically but emotionally, after so many “nothing”.

But what if I told you that this diagnosis of “unexplained” simply means we haven’t yet looked deep enough?

What Does Conventional Medical Assessment Usually Include?

Before someone is labelled with unexplained infertility, the typical tests performed are:

• Basic hormonal assessment (FSH, LH, oestrogen, progesterone)

• TSH (thyroid-stimulating hormone)

• Pelvic ultrasound or hysterosalpingography to assess the anatomy of the uterus and fallopian tubes

• Basic semen analysis (in men)

If all results fall within reference ranges and conception still hasn’t occurred, the response is “we don’t know why”. But there is so much more that can — and should — be explored to truly understand reproductive health.

Four Crucial Areas Often Overlooked

In integrative and functional approaches to fertility (female and male), we look for hidden causes: subtle inflammation, microbial imbalances, nutritional deficiencies and genetic patterns that may be interfering with conception. Here are four key areas that deserve attention:

1. Vaginal and Uterine Microbiome

Science has shown that the uterus and vagina are not sterile — quite the opposite. A healthy vaginal microbiome, dominated by lactobacilli, protects against inflammation, supports fertilisation and sustains embryo implantation.

Bacteria such as Gardnerella or Prevotella, when overgrown, are associated with lower reproductive success and longer time to conceive. Noticing a whitish discharge with stronger odour or vaginal itching? It may be more than just normal.

The good news? We can test, treat and restore that ecosystem. With targeted protocols (natural antimicrobials, specific probiotics, nutritional support), many women restore vaginal balance and significantly improve their reproductive environment.

“What if this diagnosis of ‘unexplained’ simply means we haven’t yet looked deep enough?” – Dr Andreia de Almeida

2. Comprehensive Hormonal Assessment

It’s not enough to measure FSH and progesterone. More thorough tests — such as the DUTCH test (hormone metabolites in urine) or advanced hormone panels — can uncover:

• Androgen imbalances (high or low testosterone)

• Prolactin, SHBG, insulin levels

• Prolactin (excess can inhibit ovulation)

• SHBG (a protein that modulates hormone availability)

• Stress hormones and cortisol rhythm

• Crucial nutrients like vitamin D, B12, folate, iron and zinc — all directly impacting ovulation, endometrial function and embryo quality

It’s like swapping a torch for a spotlight: suddenly, so much more becomes visible.

3. When the Cause Is Male

For a long time, the focus of fertility fell almost exclusively on women. But today we know that up to 50% of infertility is due to male factors. Even when a basic semen analysis appears “normal”, there is much that remains unexamined.

For instance: nutritional deficiencies, chronic low-grade inflammation, oxidative stress, hormonal imbalances, insulin resistance, and environmental exposures (like endocrine disruptors) can all negatively impact sperm quality, fertilisation or embryo development.

With specific lab tests and detailed clinical history, these hidden causes can be identified and addressed — often with remarkable results, both in natural fertility and success with assisted reproduction.

Good news? Antioxidants, dietary changes, toxin reduction, and lifestyle support can significantly improve sperm quality.

4. Nutrigenomic and Epigenetic Testing

Our genetics aren’t fate – they’re a map.

Nutrigenomic testing allows us to identify variants in genes such as MTHFR (methylation), COMT (oestrogen metabolism), GSTM1 (detoxification), among others. These subtle polymorphisms can affect fertility through mechanisms like poor folate absorption, estrogen build-up or difficulty handling oxidative stress.

With this data, we build a truly personalised supplementation and nutrition plan for both partners, based on their real biological needs.

In my clinical practice, this is precisely where real diagnoses begin — the ones that make sense. The questions that haven’t been asked. The tests that haven’t been ordered. The patterns the body is trying to share, but conventional exams miss.

A Real-Life Story: When a Simple Diagnosis Changes Everything

“Ana” came to me after two years trying for her second child. All tests showed everything as “normal”. IVF was suggested, but something told her there was more to uncover. We did a vaginal microbiome test, which revealed low lactobacilli and overgrowth of inflammatory bacteria.

With a plan to restore both intestinal and vaginal microbiomes, Ana conceived naturally in less than two months. Today, she is a proud mother to a healthy baby girl.

What Is Your Body Trying to Tell You?

Infertility is a signal, not a failure. It’s the body’s way of communicating that something is out of balance — and often that “something” isn’t visible on conventional tests.

Couples deserve more than an empty diagnosis. They deserve an approach that looks at the whole picture: hormones, microbiome, genetics, nutrition, lifestyle, emotions. They deserve to be heard, understood and supported with empathy and science.

If you feel ready to dig deeper, uncover the true causes, and receive support on your journey of healing and conception, this may be the moment to change your approach.

Fertility isn’t a mystery – it’s a language. And together, we can translate it.