(See also Overview of Infertility.)
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 and ovulates regularly. Other experts, who accept the definition above, recommend starting empiric treatments.
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, which has increased risks and morbidity.
COS involves the following:
Giving 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)
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 are increasingly proceeding directly to in vitro fertilization and avoiding COS.
The pregnancy rate is the same (about 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. Recent data indicate that women > 38 with unexplained infertility conceive more quickly and costs are lower when in vitro fertilization is done before COS is tried (1).
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.
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