Unexplained Infertility
It may, at first, seem disappointing that your tests have not come up with an explanation but in terms of a successful outcome, you are more likely to achieve a pregnancy either with or without treatment than if there were evidence of severe male factor problems or tubal disease. In a summary of the available evidence, it was found that clomiphene , IUI, and HMG each double the chance of conception compared to no treatment (Figure 10.8).
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Figure 10.8 Cumulative pregnancy rates for unexplained infertility. Without treatment, IUI alone, ovarian stimulation +IUI and IVF.
In vitro fertilisation and embryo transfer were originally developed for infertile women who had no Fallopian tubes or who had tubes that were irreversibly damaged. IVF and GIFT (gamete intra Fallopian transfer eggs and sperm are introduced into the Fallopian Tubes) have found places for other causes of infertility including male factor and unexplained infertility. IVF and GIFT include superovulation (increase in the number of oocytes available for fertilisation), and increasing the number of spermatozoa directly available for each oocyte. For women with no evidence of gross tubal disease, superovulation (gonadotrophin injections) and intrauterine insemination could provide some of the advantages of IVF or GIFT but with less invasive procedures and at lower cost.
Some authorities have recommended that IUI and gonadotrophin injections should be offered to couples with unexplained infertility before submitting them to IVF. A successful outcome is more likely with four courses of this combination than one course of IVF and this low-tech approach is also more cost-effective. Patients with unexplained infertility, who fail to conceive with IUI and superovulation, prove to have a higher incidence of fertilisation failure when they are treated by IVF than patients with tubal factor infertility.
Failed Infertility Treatment
Although there have been tremendous advances in the treatment of infertility, it is a matter of frustration for all concerned that a successful outcome cannot be guaranteed. Sometimes with IVF, fertilisation failure may occur and this could explain for the couple concerned why other treatments have been unsuccessful. The majority of human embryos are lost as a result of implantation failure and any treatment that may reduce this problem would be a major advance in infertility treatment. Low dose aspirin (75 mg daily) improves pregnancy rates in patients with increased antiphospholipid antibody (Q12.17).
It may be difficult to know how long to continue with your infertility treatment. Sometimes a counsellor may provide assistance. It can be particularly difficult if one partner is keen to continue and the other is not. There are times in life when it is helpful to have a plan. You may, for example, decide that you will continue for another six months or a year and then stop. One of the difficulties for you will be that inevitably, with current rates of progress, you may live in hope that a new treatment will prove effective. The medical profession never gives up and is always seeking to improve. Rest assured that however busy your carers may be, they will always have your best interests at heart and they will share with you in any success as well as failures.
The aromatase inhibitor letrozole appears to constitute a good alternative to CC-gonadotropin in patients with unexplained infertility undergoing COH cycles combined with IUI therapy.0802
A randomised controlled trial has disappointingly found that empirical clomiphene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.0803
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