Unexplained Infertility: Delving Deeper

Because my husband has a reduced sperm concentration, we have undergone intrauterine insemination twice. I have completed a thorough evaluation including ovulation documentation by LH kit testing, an endometrial biopsy and a hysterosalpingogram. What's the next step?

Question:

Unexplained infertility is diagnosed when no obvious cause of infertility is demonstrable. Laparoscopy is often utilized to determine the absence or presence of pelvic pathology yet undefined by the routine workup (history, physical examination, BBT, semen analysis and hysterosalpingogram). Pathologic findings include: endometriosis, tubal adhesions or occlusion, pelvic adhesions and uterine and/or tubal anatomy abnormalities. Treatment of many of these entities can be accomplished at the time of laparoscopy.

Laparoscopy is usually one of the last evaluations performed in an infertility workup unless historical or physical findings suggest pelvic pathology. If laparoscopy proves to be normal, or if it is felt to be unnecessary, the diagnosis of unexplained infertility can be applied. Unexplained infertility patients carry a two to six percent per cycle pregnancy rate. Spontaneous pregnancies occur in 65 percent of these couple after three years. This rate increases to over 70 percent at five years. Thus, one option may be to postpone therapies, depending on maternal age and other factors.

It has been well documented that superovulation with insemination improves the pregnancy rate per cycle compared to insemination or fertility drugs alone. The choice of which superovulation agent to utilize is best discussed with your fertility expert.

Both clomiphene citrate and gonadotropins are utilized in such situations. For clomiphene citrate, the costs are reasonable and the risk of multiple pregnancies is low at five to eight percent. When multiple pregnancies do occur, over 95 percent are twin pregnancies.

Gonadotropins should be administered by experts trained in their use and monitoring. They increase the multiple pregnancy rate to 25 to 30 percent and the risk of high order multiple pregnancies are one to eight percent overall. In addition, gonadotropins also substantially increase the cost of therapy. Gonadotropin cycles are cancelled in 10 to 20 percent of cycles because of an exaggerated or minimal response. Ovarian hyperstimulation syndrome may occur in one to four percent of cycles using gonadotropins.

When unexplained infertility is diagnosed., treatment options include no intervention, intrauterine insemination, empiric clomiphene cycles with or without insemination, superovulation with insemination using gonadotropins, GIFT and IVF. Evaluation of each individual situation will help determine the most advisable course of action.

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