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Unexplained infertility: what is the best treatment ?

Anil Gudi, Amit Shah & Prof Homburg

What could be more frustrating than trying to get pregnant for two years and performing all the initial tests which turn out to be normal? This is so-called unexplained or idiopathic infertility. Some advocate waiting for a further year for younger patients and indeed there will probably be a handful of pregnancies using this ‘expectant’ management. However, the vast majority of couples prefer an active treatment approach. The question is, what should be the form of this treatment in a couple in whom the wife is ovulating with open tubes and a man with normal sperm? The accepted treatment is to stimulate the ovaries to produce more than one ovulation per month and to select the best moving, washed, normal sperm to be introduced into the cavity of the uterus. The thinking behind these procedures is that hormonal stimulation, as well as increasing the number of ovulations, may also improve the hormonal environment which would be more conducive to pregnancy and the selection of the best sperm introduced nearer the egg would shorten the sperms’ journey. Using clomifene for stimulation of the ovary has proved relatively ineffective so injections of FSH are preferred. For women under the age of 38, this treatment can be expected to yield a pregnancy rate of between 12-25%. Over this age, treatment by IVF is usually preferred.

Very recently, the National Institute for Clinical Excellence (NICE), recommended offering IVF as the first-line treatment to all women with unexplained infertility of more than two years standing. This is controversial as IVF is a much more invasive and costly treatment and more of a strain on the couple. It is not clear whether the probable slightly increased pregnancy rate using IVF justifies the exclusion of treatment with ovarian stimulation and insemination of prepared sperm into the uterus (IUI). This question will be a focus of our research in the year to come and will hopefully give us an answer as to what should be the best first-line approach to the problem of unexplained infertility.

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