When ‘unexplained’ infertility has no clear answer

Learners: “A nuclear family consists of a mother, father and children.”

Teacher: “Again!" A nuclear family consists of a mother, father and children.”

They all erupt in unison, this time louder than the first time. Well, this is their lesson for the social studies learning area.

This may be the case or otherwise because some families consist of a mother or just a father- single-parent or a one-parent household- or couples without children. And that is still family.

Keith, a dedicated pastor, is preparing to head out to a baptismal event. He woke up early this day, had his devotion, read his bible, and tended to his cattle: two cows and three goats.

He now sits outside his house with his brown pair of shoes on and blue socks.

Before then, we have a sit-down to speak about his experience. Children.

For more than a decade, Pastor Keith has spent his life celebrating other people's children.

He has prayed for parents. He has baptised babies.

He has stood before families as they welcomed new life and offered blessings over children whose arrival represents moments of joy for their parents.

But when the service ends, and he returns home to his wife, Ruby, an accountant at a local school, there is a deeply personal question that neither prayer nor years of medical investigations have answered.

Why have they never had a child of their own?

Keith and Ruby have been married for more than ten years.

They have gone through fertility investigations, including assessments of ovulation, the fallopian tubes and semen analysis. They have sought medical explanations for their inability to conceive.

But after all the tests, there has been no single identifiable cause.

They are among couples who may be described as having unexplained infertility; infertility in which standard investigations do not identify a clear reason for the failure to achieve pregnancy.

For the couple, however, “unexplained” is not an easy word to live with.

“It does not tell us why,” Keith says; he looks away, glistening with tears as though searching for an answer.

It does not tell them what they could have done differently.

And it does not necessarily tell them how long they should continue trying, waiting or pursuing treatment.

“I am the third-born in a family of six boys, Ruby my wife is the second-born in a family of four one girl and three boys,” Keith points out.

Both grew up surrounded by siblings. Children were part of their family experiences long before they began thinking about having children themselves.

When they married, they expected that parenthood would eventually become part of their own story.

Instead, more than ten years have passed, and the child they hoped for has not come.

The pastor and the unanswered prayer

Keith's experience is complicated by the work he does.

As a pastor, he is often present at the beginning of other children's lives.

He watches parents celebrate milestones that he and Ruby have longed to experience themselves.

That creates a contrast that is difficult to ignore.

He is a man whose public role involves offering encouragement and spiritual support to families, yet privately he and his wife have had to confront a question for which medicine has not provided an answer.

Their faith remains part of their lives.

The couple worship at a friend's Quaker church, where they continue to participate in a community that includes families with children.

But faith does not make infertility disappear.

Nor does it shield a couple from the questions that come from relatives, friends, neighbours and even strangers.

For Keith and Ruby, there is stigma.

“You can always see stigma in the most subtle ways; people keep quiet when I appear, some avoid making eye contact, I am greeted warmly by some people and cautiously by others. Others exchange glances before responding and such like things. The list is endless.

And there is the pressure that comes when people assume that a married couple should eventually have children.

Sometimes, the most difficult burden is not what people say directly.

It is what couples begin to tell themselves.

Did we wait too long? Is something wrong with me?

Is something wrong with my spouse? Should we try another doctor?

Another treatment? Another test?

Or should we simply accept that we may never know?

When all the tests have been done

The medical investigations are important because unexplained infertility is not simply a situation in which a couple has never been tested.

The diagnosis comes after an evaluation has failed to identify a clear cause.

The World Health Organization defines infertility as failure to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse and recognises that infertility can arise from male, female or unexplained factors

For Keith and Ruby, the investigations have already happened.

Their reproductive health has been examined.

The couple have undergone tests looking for possible explanations, including assessment of ovulation, the fallopian tubes and male fertility through semen analysis.

Yet there is no single diagnosis they can point to.

That can make unexplained infertility uniquely difficult.

When a test identifies a blocked fallopian tube, for example, a doctor can explain what has been found.

When semen analysis identifies a male-factor problem, there is a medical finding to discuss.

When ovulation is affected, treatment can be directed at that problem.

But when the standard investigations do not reveal an explanation, the couple can be left with uncertainty.

That is the medical reality behind the phrase “unexplained infertility.”

It does not necessarily mean there is no biological reason.

It means that current clinical evaluation has not identified one.

What happens after the diagnosis?

This was the focus of a September 17, 2026 WHO Infertility Guidelines Dissemination Series virtual meeting organised with the International Federation of Fertility Societies.

Dr Cindy Farquhar of New Zealand presented the evidence base for the management of unexplained infertility, while Dr Richard Kennedy of the United Kingdom discussed pathways of care.

The WHO guideline recommends a staged approach that takes account of evidence, patient preferences and the availability and acceptability of care.

For couples with unexplained infertility, the guideline places expectant management among the initial options. This means allowing some time for natural conception rather than immediately moving to more complex treatment.

The guideline also says unstimulated intrauterine insemination; a fertility treatment in which specially prepared sperm is placed directly into the uterus around the time of ovulation.

The aim is to increase the chance of sperm reaching and fertilising an egg, and ovarian stimulation with timed intercourse offer little or no benefit compared with expectant management in the evidence reviewed.

Where treatment is pursued, stimulated intrauterine insemination (IUI) using medicines such as clomiphene citrate or letrozole; medicines that can stimulate ovulation – release of an egg from the ovary is recommended as a second-line option in appropriate circumstances.

If stimulated IUI fails, the guideline conditionally recommends IVF (In vitro fertilisation) a fertility treatment in which an egg is fertilised by sperm in a laboratory, rather than inside the body as a subsequent option.

The recommendations are not absolute prescriptions for every couple. Several are conditional, and the certainty of evidence is low or very low for some interventions.

That matters.

For someone who has already spent years trying to conceive, a treatment pathway can sound straightforward on paper.

In real life, however, every step can mean another consultation, another procedure, another bill and another period of waiting.

The cost of waiting

For Keith and Ruby, their story therefore raises an important question about the place of time in infertility care.

How long should a couple wait before moving from natural conception to treatment?

How should doctors determine who may benefit from waiting and who may need to progress more quickly?

And what happens when a couple cannot afford the next step?

“The procedures are very expensive and have drained us,” Keith says.

The WHO guideline itself identifies evidence gaps, including uncertainty around the optimal duration of expectant management and the use of prognostic tools to guide decisions.

Kennedy in his presentation said “Infertility treatment is not simply a sequence of medical procedures but a pathway in which clinical findings, available evidence, patient circumstances and preferences all matter.”

For a couple like Keith and Ruby, that pathway is being lived rather than merely discussed.

The burden beyond medicine

Infertility is also a social and emotional experience.

WHO says infertility can cause significant distress, stigma and financial hardship and can affect mental and psychosocial wellbeing. The organisation's guideline therefore emphasises the need for psychosocial support as part of fertility care.

That is a reality Keith and Ruby know.

Keith in his work celebrates their children while carrying his own unanswered questions privately.

What happens when treatment fails?

For Keith and Ruby, the question now extends beyond diagnosis.

They have already had the tests.

They know what has been investigated.

But knowing that no clear cause has been found does not tell them what their future will look like.

If treatment fails, do they try again?

How many times? At what financial cost?

And when does continuing treatment become too emotionally or financially demanding?

These are not questions that medicine can answer for every couple.

They require conversations between patients and clinicians about evidence, prognosis, treatment options, risks, costs and personal preferences.

That is why the WHO guideline calls on countries to adapt evidence-based recommendations to their own health systems and work towards more accessible and equitable fertility care.

For couples in countries where fertility services may be paid largely out of pocket, the question of access becomes particularly important. WHO has noted that infertility care is often not prioritised within national universal health coverage packages and that treatment costs can create severe financial hardship.

In Kenya, the 2024 SHA benefit regulations explicitly excluded assisted fertility treatment, including IVF, from the general benefit package. The 2026 proposed SHA tariff framework also lists assisted fertility treatments such as IVF among the exclusions. There is, however, an important new exception for teachers: in April 2026, IVF was added to the SHA Mwalimu Comprehensive Cover for eligible teachers and their spouses, subject to specific eligibility conditions and limits.

Living with the unanswered question

Keith and Ruby's story is ultimately not only about wanting a child.

It is about what happens when a couple has done what medicine asks of them but, the explanation does not come.

For more than ten years,Keith has returned home to the reality of his own unanswered longing.

For Ruby, there is the same uncertainty, accompanied by the social expectations that often place motherhood at the centre of a woman's identity.

Their experience shows why an “unexplained” diagnosis should not be mistaken for an insignificant one.

The absence of an identifiable cause does not mean the absence of suffering.

And when the tests are finished but the answer is still missing, the next stage of infertility care is not simply about finding another test.

It is about helping couples understand what is known, what remains uncertain, what options exist, what those options cost and how they can make decisions without carrying the burden alone.

For Keith, that means continuing to serve families while living with a question that has followed him home for more than a decade.

He can tell other parents that their children are blessed.

What he still cannot explain is why, despite all the tests, he and Ruby are still waiting for their own.