Diagnosing & Treating Unexplained Infertility!

By Dr. Aanchal Agarwal, Sr. Consultant, IVF and Infertility Treatment, BLK Super Speciality Hospital, Pusa Road, New Delhi 110005.

When the results of a standard infertility evaluation are normal, we assign a diagnosis of unexplained infertility. This may also mean that the presently available tests and techniques are unable to pick up the cause what so ever. Approximately 15% to 30% couples will be diagnosed with unexplained infertility after their diagnostic work up.

The standard tests include:

  • Semen analysis for the male partner
  • For female partner: assessment of ovulations through history / ultrasound / urine / blood tests
  • Assessment of uterus and fallopian tubes:
    • HSG / Laparoscopy for tubal evaluation
    • Ultrasound for evaluation of uterus and to rule out polyps / fibroids / synechiae / malformations

Role of Laparoscopy in Unexplained Infertility

Given that it allows direct visual examination of the pelvic reproductive anatomy, it is the test of choice to identify otherwise unrecognized potential/tubal/ovarian factors that influence fertility especiallyendometriosis and pelvic adhesion.Laparoscopy should always be combined with hysteroscopy for complete evaluation of uterus along with tubes, ovaries and peritoneum.

Expectant observation with timed intercourse and lifestyle changes

Includes correction of thyroid and Prolactin, achieving normal BMI, reduction of coffee intake to 2 cups in a day and reduction of alcohol intake to not more than four standardized drinks per week. All these with proper understanding of fertile period can produce a successful pregnancy in 1.3% to 4.1% of couples. This is based on the understanding that routine infertility evaluation misses subtle defects. Although expectant management is associated with the lowest cost, it results in lowest cycle fertility rate and is therefore inferior to the commonly available reproductive techniques outlined below.

Ovarian stimulation with IUI

Rationale is that subtle ovulatory defects missed by standard testing may be overcome, and that multiple ova available for the fertilization may increase the chances of pregnancy. Also, introducing washed sperms into the uterine cavity increases the number of sperms available for fertilization. This method offers a success rate of 15% to 16% per cycle.

IVF – ICSI

The most successful treatment for unexplained infertility is IVF – ICSI. ICSI can take care of an undetected fertilization problem. As per the SART 2006 data, there were 126,726 completed cycles with 40.4% live with rate for women < 35 years of age and 38.9 % for women 35-37 years of age. This process also facilitates selection of good quality embryos thus, helps to overcome defects in implantation as well. Thus, IVF & ICSI treatment is the choice in the case of unexplained infertility. It may be expensive as compared to other treatment methods but it also offers the highest success rate.