(See also Overview of Infertility Overview of Infertility Infertility is a disease defined by the inability to achieve a pregnancy and/or the need for medical intervention to achieve a successful pregnancy. In patients who have not achieved a pregnancy... read more .)
Some experts disagree with this definition and recommend continuing to test for other causes even when the man has normal semen and the woman has normal ovulation and fallopian tubes. Other experts, who accept the definition above, recommend starting empiric treatments.
Treatment of Unexplained Infertility
Controlled ovarian stimulation
In vitro fertilization
(See also Evidence-based treatments for couples with unexplained infertility: A guideline, from the Practice Committee of the American Society for Reproductive Medicine.)
Controlled ovarian stimulation (COS) can be used to make pregnancy more likely and to achieve it sooner. This procedure stimulates development of multiple follicles; the goal is to induce ovulation of > 1 oocyte (superovulation). However, COS may result in multifetal pregnancy Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more , which has increased risks and morbidity.
COS involves the following:
Giving letrozole or clomiphene, with human chorionic gonadotropin (hCG) to trigger ovulation, for up to 3 menstrual cycles
Intrauterine insemination within 2 days of hCG administration
If pregnancy does not result, use of gonadotropins (preparations that contain purified or recombinant follicle-stimulating hormone and variable amounts of luteinizing hormone) with hCG to trigger ovulation, followed by intrauterine insemination (some clinicians begin with gonadotropins rather than clomiphene or letrozole)
A progestogen may be needed during the luteal phase to maximize the chance of implantation. Gonadotropin dosage depends on the patient’s age and ovarian reserve.
Because multifetal pregnancy is a risk, clinicians often proceed directly to in vitro fertilization In vitro fertilization (IVF) Assisted reproductive technologies (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. For assisted reproductive technologies, oocytes and... read more and avoid COS.
Prognosis for Unexplained Infertility
The pregnancy rate is the same (approximately 65%) whether in vitro fertilization is used immediately after unsuccessful treatment with clomiphene plus hCG or whether gonadotropins with intrauterine insemination are used next before trying in vitro fertilization.
However, when in vitro fertilization is done immediately after unsuccessful treatment with clomiphene plus hCG, women become pregnant more quickly and high-order multifetal pregnancies (≥ 3 fetuses) are much less likely than when gonadotropins are used first. Thus, if clomiphene plus hCG is unsuccessful, more clinicians now recommend in vitro fertilization as the next treatment. Data indicate that women > 38 years with unexplained infertility conceive more quickly and costs are lower when in vitro fertilization is done rather than proceeding to controlled ovarian stimulation (1 Prognosis reference Infertility is usually considered unexplained when semen in the male partner is normal and oocytes, ovulation, fallopian tubes, and uterus are normal in the female partner. (See also Overview... read more ).
1. Goldman MB, Thornton KL, Ryley D, et al: A randomized clinical trial to determine optimal infertility treatment in older couples: The forty and over treatment trial (FORT-T). Fertil Steril 101(6):1574–1581, 2014. doi:10.1016/j.fertnstert.2014.03.012
Drugs Mentioned In This Article
human chorionic gonadotropin
|Novarel, Ovidrel, Pregnyl