Looks Good on Paper: Why Normal Fertility Tests Don’t Guarantee Pregnancy

Fertility tests can look perfect on paper—and pregnancy still doesn’t happen.

In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols breaks down why many fertility treatments, especially IUI, are built on assumptions rather than certainty. Tests like the HSG can confirm that fallopian tubes are open, but they cannot prove that the tubes are functional. Semen analysis can look normal, but it cannot confirm that sperm can reach the egg or successfully fertilize it.

This gap between testing and reality is why IUI often requires a leap of faith—and why it works well for some patients but not for others.

In this episode, Dr. Amols covers:

• What fertility tests can—and cannot—tell us
• Why “normal results” don’t guarantee pregnancy
• Why IUI is assumption-based by design
• Who is more likely to succeed with IUI
• Why patients with long-standing infertility face harder decisions
• The difference between assumption-based treatment (IUI) and information-based treatment (IVF)
• Why IVF often provides answers even when it doesn’t lead to pregnancy

If you’ve ever wondered why IUIs fail despite normal testing—or whether it’s time to move on to IVF—this episode explains the logic behind those decisions without pressure or judgment.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

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Today we talk about the assumptions we must make and the leap of faith we must have when going through fertility treatment after doing testing. I'm Dr. Marc Emils, and this is Taco about Fertility Tuesday. So what do I mean by assumptions that we make? Well, when we do tests in fertility, these tests are good, but they're not perfect. And because they're not perfect, we make assumptions that there are certain things that are not there that could affect the outcome of treatment. I think one of the best examples is unexplained infertility. It doesn't mean there's not a problem. It just means we don't know what that problem is because there aren't tests to test everything. Let's talk about that. Let's first start with a semen analysis. A semen analysis looks great. All the numbers are perfect, the motility is perfect, even the shape is perfect. And yet you're not getting pregnant. And as you've heard me say in other podcasts, men should not get a pass. Just because their test is normal doesn't mean the sperm is working. Previous examples I've talked about are football players and basketball players. They're expected to be the number one pick, and they look amazing on paper. Matter of fact, they look amazing in college, and yet they get to the NFL or the NBA and they don't do well. Now, why is that? Because all of the decisions were made on performance at a different level and measurement based off of their body dimensions, as well as their performance on things like jumping high. But those don't always mean it's going to produce a great player. And the same thing goes for sperm. Just because it looks good on paper doesn't mean the sperm is going to be able to get to where it needs to get. But we could even go a step further. Just because the sperm looks good and we know it's getting the egg, we still don't know if the sperm's getting into the egg. As a matter of fact, that's impossible to know. The only way to know that is is by taking the sperm, putting it with the egg next to it, and watching if it can get in. Years ago, they used to use hamster and mouse egg penetration assays looking at the sperm's ability to penetrate the egg. But this was abandoned because it was not able to be reproduced and it had limited clinical usefulness. So here's one of the big leap of faiths we have to have. We have to assume that when we do things like artificial inseminations and IUIs that the sperm can penetrate the egg. And unfortunately, there is absolutely no way to determine if it can prior to testing an IVF and putting the sperm with the eggs. Even if those sperm could penetrate someone else's eggs, it doesn't mean it can penetrate your eggs. And so we have to make the assumption that the sperm can fertilize the egg when moving forward with IUIs. But the assumptions don't just stop with the men. We have to. Also on the female side, for example, when you do an HSG and you see that the tubes are open, that's fantastic. We know for sure that your tubes are not blocked. But does that tell us the tubes work like the cilia, or that the tubal transporting is working, or if the tube is spasming, or if there could be inflammation in the tube? Fluid may come out of the tube, but that doesn't mean the inside of the tube isn't pathologically affected or that the little fimbriae are pulling the egg towards it. Again, we have to make a large assumption, and there's really no way to determine that. Sure, if you look with a laparoscopy, you will see that the tube is abnormally shaped and you'll know, okay, that tube is scarred. So clearly in that situation you'd say, okay, we're not using these tubes. But just because the tubes look normal doesn't mean they're functional. And that's a really important part here. Open does not mean functional, and normal does not mean effective. And this is the core problem. There's only so much we can test. Now, these are two big areas that I'm talking about, and specifically I'm talking about when you're doing IUIs, because one question I get asked a lot is, do you think it's going to work or am I going to waste time? And that is a very difficult question to answer because IUIs are, ah, built on assumptions. Those are the two big ones I'm talking about. If those are off, there is no chance that IUI is going to work. But what do we have to assume when doing IUIs? Well, we have to assume that you ovulate correctly and that the tube then captured the egg and that the tube then transported that egg down towards the uterus and the sperm eventually reached the egg and was able to penetrate the egg and that fertilization occurred normally. Meaning, yeah, it may have, fertilized. But did it fertilize normal. And then did the embryo ever make it to the uterine cavity? See in ivf Some of this stuff we can see. If the next day we come in and the sperm's not attached to the eggs, we know there's a problem. It's not connecting to the eggs. If we look the next day and we noticed Instead of being 2 pns, the eggs fertilized and created 3 pns or 0 pns, then we know it did fertilize, but it fertilized abnormal. and if you were doing IUIs, you would never know. And that's because you can't see that. Again, assumptions. And here is the fear. You don't want to waste time, and I appreciate that. And so making assumptions can be a little bit stressful because you feel like, what if I waste time? And so I want to kind of go over a couple different situations that can kind of help you guide your choices when trying to make this decision. Now, it's important to understand if you have male infertility. Yes, IUI makes sense, especially if there's just a minor problem. So this is really pointing towards people who have unexplained infertility or kind of unknown. And so the way I would break up, the two patients are going to be patients who have been pregnant before and then who are now having problems. In that situation, you've been pregnant. So if it's unexplained, IUIs are probably going to work. Unless it's been more than three years. And then in that situation, you start to think there's something bigger going on. Maybe there's endometriosis you don't know about, but if you've been pregnant before, at least you know, a lot of this stuff works. Now, your doctor still needs to look at your history and go, oh, wait, well, she had pid, which is pelvic inflammatory disease. Well, then your tubes might be blocked or be deformed. And for that reason, it may not work, but that's something your doctor will help you determine. But if you're someone who's been trying for three to five years or more, you've never had a pregnancy, then those assumptions become a little bit scary, because it is possible those may be there, and the IUIs will never work. And like I always say, if everything's free, go for it. What's the harm? IUIs are way easier than doing IVF. But the reason you hear that a lot of people say IUIs don't work is not because they don't work, is because a lot of doctors do it when it's not needed and it's the wrong treatment. For that patient, I see people all the time with sperm counts are very poor, or a patient with a history of appendix, that ruptured and yet they still try IUIs. The point is, if you are the right type of patient to do an iui, it has a very good chance of working. The question is, is your doctor putting you in the best position? And two, are they giving the right treatment? This is another area I see problems with, where someone will, let's say, be 40 and doing the same treatment of an IUI as someone who's 26, it's not going to work. It doesn't mean it can't work. But statistically, because there's so few eggs being made at that age, your chances are not 50%. After doing three I've UI cycles, it's going to be lower, maybe 20, 30%. The point is, no matter what your situation is, as you see, we have to make some assumptions. When you do IUIs, even if your doctor believes 100% it's going to work, which really no doctor does, but let's say we believed 100% it would. If those assumptions are not true and your tubes are not functional, or, or the sperm cannot fertilize the eggs, it doesn't matter how many IUIs we do, you will not get pregnant with IUIs. And that's where IVF comes in. It bypasses those things. So in those situations, it doesn't matter if the sperm can't get in the egg or if the tube's not picking up the egg because you're bypassing them. And sure, if IVF was easy and free, probably everyone would do it because then they don't have to make those assumptions. But in reality it's not. So why do we Even then try IUIs? Because we know there's this assumption you have to make. And there's a lot of people who may not get pregnant because they never had a chance. Well, the reason is because they're lower cost, they're much less invasive. Emotionally, they're a lot easier too. There's a little less writing on them. And because they do work. It's just that, unfortunately for some people, it doesn't. Whether it's because they're not a good candidate for it or because those assumptions we made were not met and there was something wrong. Now, one major downfall of IUIs, in my opinion, is that when it doesn't work, no one really knows why. Now, clearly the sperm comes back in severely low. We'll say, okay, this is the problem. You're going to have to go on the ivf. But if that's not the issue, I can't tell you because the tube didn't pick up the egg. I can't tell you the sperm didn't make the egg or that the sperm didn't fertilize them. No one can because we can't see it. That is one of the biggest benefits of ivf. We get direct evidence did fertilization occur, we get direct evidence how the embryos grew, and we can have a better idea of why things fail and can make the adjustments that make it successful versus making assumptions in the end, this is not to make you afraid of doing IUIs. I just want to make sure it's obvious that when we're having this leap of faith conversation, IUIS assumption based IVF equals information based. Neither is right or wrong, but the decision depends on things like age, how long you've been trying, if you ever had the prior pregnancy, your emotional bandwidth, and even financial. The point is, don't be discouraged if an IUI doesn't work, because maybe it never could work because those assumptions we made, which were fair assumptions, unfortunately were wrong. If anything, you should be optimistic because then you're going on to a treatment that's information based. Remember, there is no wrong or right. It's always important to talk to your doctor and make sure that treatment is best for you. Yes, there are some doctors who just put everyone through iui, even if they shouldn't be, and I don't agree with that. Doesn't make them a bad doctor. I just don't agree with that. So if you're in a situation where you feel like you shouldn't be doing IUIs, ask them, why am I doing this? Is it really something I should do? Sometimes insurances require you to do it first, even when we know it won't work. But it's never wrong to ask your doctor why. And keep in mind, even if they think it will work, even if they think you're the greatest candidate for iui, everyone still has to make those assumptions. And if those assumptions are wrong, the IUI will not work. Hopefully you found this podcast helpful. Maybe you're going through IUIS or you have a friend. Maybe this may help them too. Going through IUIs, they can be quite stressful sometimes because you feel like you may be going the wrong path and you feel like you can't see anything and so you don't know if things are working. But it's important to understand that even if you fail an iui, you can still have success with the next IUI or even ipf. It's just important that you let your friends know that you do have to make assumptions when doing IUIs, and it's not that your doctor failed you when the IUI doesn't work, but more likely there's those assumptions we made that were wrong. If you like this podcast, please tell your friends about it and if you can, give us a five star review on your favorite medium. I really do enjoy doing these and looking forward to this season of talk. about Fertility Tuesday. I have several guests that are going to be coming on this year, so we're going to make a few changes and excited to share more. If you have ideas for the podcast, always send them to tbftewdirectionfertility.com I'm more than happy to do a podcast on that topic. I look forward to talking again next week on Taco Belt Fertility Tuesday.