Guest post by Ingrid A. Rodi, MD - Pacific Fertility Center-Los Angeles
Clinical Professor (Voluntary)
Department of OBGYN
David Geffen School of Medicine at UCLA
The first question most patients have when they get a diagnosis of unexplained infertility is, “now what?” What does not get conveyed with that diagnosis is that, in general, it is good news. Many couples go on to get pregnant without any treatment.
When a couple is planning on starting a family, it is a good idea to get preconception counseling, an exam, and lab work. The goal is to identify problems that are best taken care of before conception, as well as to identify problems which might get in the way of conception. For example, a woman who only has a menstrual period 6 times a year should not to be told to wait a year before undergoing treatment. A woman who is under or overweight should try to have a BMI between 20 and 25.
Once a couple has been given the “green light” the recommendation is to try for 1 year before seeking treatment. That is especially true for women under 35 years of age. Older women are often told to only try for six months. That is not because women over 35 get pregnant faster, but rather because they don’t have as much time.
When the couple presents for evaluation, the following are evaluated:
The presence of ovulation
The presence of sperm
At least one open fallopian tube
These issues are evaluated first because each one is essential to success. When all are present, conception is possible, and then the issue is how to help the process along.
So, getting a diagnosis of unexplained infertility is actually not that bad. Even so, the question remains: “Now what?” The answer to that question depends on several factors. The most important one is the woman’s age.
Women are the most fertile in their mid-twenties. After that, fertility declines gradually until, in the mid-forties getting pregnant is the exception rather than the rule. The older the woman is, the more important it is to start treatment as soon as possible and be as aggressive as possible.
The next factor is desired family size. If a woman is in her twenties, and the diagnosis is unexplained infertility, it would be reasonable to keep trying for 6 months longer. However, if the woman is over 35, and if she would like to have more than one child, it would make sense to move on to in-vitro fertilization (IVF) or perhaps, even embryo banking for a second child.
The treatment of a couple with unexplained infertility needs to be individualized, taking into consideration not only medical facts, but also the couples personal preferences.
For people struggling with unexplained infertility, it's advisable to keep the following options in mind:
IVF There is good evidence that for women 38 years or older, IVF can reduce the time to pregnancy. Women younger than 38 years of age, can attempt oral medications and IUI, before proceeding to IVF. Women who are 35 years or older and want 2 or more children, can consider embryo banking prior to treatment for the first baby.
Preimplantation genetic testing for aneuploidy (PGT-A) PGT can be considered for couples who have many embryos and want to prioritize transferring the ones that are most likely to result in a baby. As women age, the proportion of abnormal embryos goes up. Day 5 or 6 embryos, blastocysts, can be biopsied and evaluated for chromosomal abnormalities. Embryos that are euploid, in other words did not have any problems identified, are much more likely to result in a baby.
Low-dose oral medication and insemination There is strong evidence that only insemination for couples with unexplained infertility is not better than “just trying” or expectant management. So, it is necessary to combine treatment with clomiphene or an aromatase inhibitor, such as letrozole, with the intrauterine insemination (IUI). The recommendation is to consider 3 or 4 of these cycles.
Consistency Some couples come into be evaluated. If no serious reason for delay in getting pregnant is found, they prefer to keep trying for a period of time. It is important to let them know what the anticipated success of that approach might be.
So, it's important to remember that a diagnosis of unexplained infertility is not always bad news, and does not suggest that nothing further can be done.