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Unexplained infertility

Mr Anil Gudi ,Mr Amit Shah & Prof Roy Homburg

Unexplained infertility usually refers to a diagnosis or, more correctly, the lack of a diagnosis, made in couples in whom all the standard investigations such as tests of ovulation, examination of the tubes and semen analysis are normal. Unexplained infertility is a term that has been applied to as many as 30-40% of infertile couples. The fact that unexplained infertility is so common really tells us that our routine diagnostic tests are not accurate enough to diagnose subtle defects that may be causing the infertility and even highly sophisticated tests may fail to detect very subtle abnormalities which are responsible for the infertility.

A couple is usually referred for investigation after trying unsuccessfully to conceive for a year although the official label of unexplained infertility is applied after two years of regular unprotected intercourse. For the infertile couple, a “diagnosis” of unexplained infertility may be very frustrating and is often interpreted by them as meaning that if there is no explanation for the cause of infertility, there is, therefore, no effective treatment. Importantly, the outlook is worse when the duration of infertility exceeds three years and the female partner is >35 years of age in which case treatment should be started early. If the duration of infertility is less than two years the prognosis is relatively good even without therapy, unless the female partner is >35 years.

Because the exact cause of unexplained infertility cannot be pinpointed, treatment is usually aimed at improving subtle defects that may be present in ovulation, hormonal environment and sperm efficiency that have remained undetectable. Ovulation and hormonal environment are “boosted” by stimulation of the ovaries with medications such as clomifene but much more successfully with follicle stimulating hormone (FSH) injections. This is combined with laboratory treatment of the sperm which is washed, the most mobile sperm separated and then injected into the cavity of the uterus at the time of ovulation (intra-uterine injection or IUI). This treatment is likely to yield a pregnancy in about 15% of treatment cycles. If it fails after 2-6 treatment cycles, depending on the age of the female partner, then in-vitro fertilisation (IVF) is the last line of treatment.

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