Dr.Harshlata Ladda
Consultant infertility specialist
Samarth Test Tube Baby Centre
Aurangabad
Definition
- Unexplained infertility usually refers to a diagnosis (Or lack of diagnosis) made in couples in whom all the standard investigations such as test for ovulation, tubal patency and semen analysis are normal .
- Incidence –it is around 15 to 20 %.
- It does not mean that there is no reason for infertility. Only the thing is the reason is not identified at that time.
- The present baseline investigations do not identify these etiological factors.
Impact
- Extremely frustrating for couple as they interpret it as – No explanation for the cause of infertility means no effective treatment.
- Requirement for diagnosis—
- Normal semen analysis
- Ultra sound evidence of ovulation , normality of uterus .
- Patent fallopian tube (by HSG or HLS ).
Normal endocrine evaluation like FSH ,LH , TSH ,PROLACTIN
Unexplained infertility
What is wrong then if everything is normal?
Cases in which the standard infertility testing has not found a cause for the failure to conceive. Unexplained infertility is also referred to as idiopathic infertility.
Another way to explain it is the “doctors can’t figure it out”
Important concerns—
- How to approach the diagnosis?
- How the patient is to be evaluated?
- On what aspects we should think ?
- What are the possible treatment option ?
Standard basic investigations
- Basic semen analysis
- Medical history – Risk factors, behaviour patterns ,duration of infertility, prior fertility, childhood illnesses ,developmental history ,systemic medical illnesses, prior surgeries.
- Sexual history- H/O STD’S ,coital frequency and timing.
How to approach the diagnosis?
- Unexplained infertility is diagnosis by exclusion .
- Recent guidelines by Royal College of Obstetrician and Gynaecologist recommended that the essential investigations consists of semen analysis , midluteal serum progesterone levels and tubal patency test by HSG or HLS.
How the patient to be evaluated ?
- The Practice Committee of the American Society for Reproductive Medicine (ASRM) has published guidelines for a standard infertility evaluation.
- It includes a semen analysis, assessment of ovulation, a hysterosalpingogram, and, if indicated, tests for ovarian reserve and laparoscopy.
- When the results of a standard infertility evaluation are normal, practitioners assign a diagnosis of unexplained infertility.
On what aspects we should think ?
- In a young couple below 30 years , if married life more than 1 year , one can investigate them as above guidelines and with simple assurance one can try for few months.
- In a young couple if married more than 2 to 3 years ( female age < 30 yrs ), initial treatment can be started.
- In a patients between 30 to 35 yrs regardless of the married life one can be aggressive for super ovulation and intrauterine insemination ( IUI ).
- In a couple , female age > 35 yrs , treatment has to be more aggressive in terms of IVF .
- Even in the young couples , with long standing unexplained infertility with repeated IUI failures , patient can be directly selected for IVF.
Treatment…..
- Treatment is emperic as it doesn’t address any specific defect or functional impairment .
- Principal treatment include-
- Expectant observation with timed intercourse
- Lifestyle changes
What are the possible treatment option?
- Lifestyle Changes—
- The likelihood of pregnancy without treatment among couples with unexplained infertility is less than that of fertile couples but greater than zero.
- Epidemiological studies indicate cigarette smoking, abnormal body mass index (BMI), and excessive caffeine and alcohol consumption reduce fertility in the female partner.
- The female partner should be counselled to achieve a normal BMI, reduce caffeine intake to no more than 250 mg daily (2 cups of coffee), and reduce alcohol intake to no more than 4 standardized drinks per week.
THE ART OF LIVING
- Lifestyle changes…destressors
- Exercise /Diet / Wt Loss
- Yoga / Meditation
- Acupressure /Acupuncture
Expectant management
- Important role in limited resource situations
- Several large studies established its role
- 1-4% couples will conceive spontaneously every month
- Couple trying >2years or wife >35yrs of age- More aggressive treatment required
Ovulation Inducing agents—
Many options available in market like Clomiphene citrate , Letrozol , Aanostarzole etc
Single Vs double IUI
Many times this has created confusions in the mind of doctors as well as patients also, but many studies are showing not much difference is success rate between these two.
- Some studies have suggested marginal benefit of double IUI over single
- Randomized controlled trial concluded that results of single and double IUI do not statistically differ in COH/IUI
- Therefore double IUI is not routinely offered
- Ovulation Induction with IUI—
- Many studies has reported pregnancy rates with IUI of about 10 to 17 % each cycle , with 85 % of conceptions occurring within the first 4 cycles.
ART(IVF with or without ICSI)
- Most expensive but also most successful
- Treatment of choice if other less expensive and less successful t/t fails
- Rationale-
1/ Increases the no. and quality of oocytes available for fertilization
2/ Facilitate sperm oocyte interaction
3/ Document the occurrence of fertilization and evaluate embryo quality