Policies The ovulation disorders, tubal disease, peritoneal factor, endometriosis, uterine abnormalities, semen/sperm abnormality or unexplained can be responsible for infertility.
If the ovarian cycle was found to be ovulatory, with good PCT which excludes cervical and male factors, in marriages of short duration, expectant management up to three years is suggested for the women less than 30 years of age. The couple is explained the fertile periods of the wife. They are asked for regular sexual intercourse in fertile period for 3-6 months. There have been many instances where the wife became pregnant after the PCT. Probably the circumstances, let them be together rarely at the right time.
In overanxious couple seeking advice within a year of marriage understanding & the reassurance is the approach. The wife is asked to record her early morning temperature on a specially designed chart. Rise of 0.5-1.0 0 F follows ovulation due to progesterone. It then remains high. This helps the couple to know if they used right time for coitus.
In longer duration marriages, or if the case is at high risk of tubal or peritoneal factor, endoscopic evaluation is done for appropriate decision.
Both the partners are advised to avoid smoking , alcohol and other addictions. Obese woman are advised to reduce weight.
Ovulation disturbances are the only factor that can be treated medically. Experience has shown that for all other factors, ART is the only course and end choice. Other treatments in the hope that they may work is misconception. Women do get pregnant even without a treatment.
We rely too much on observations of one or two cycles or give up as unexplained infertility. With the exception of organic lesions all the physiological events in a woman are variable. In such cases there is no limit of time to success. Hope should never turn into despair.
Unexplained Infertility accounts for 10-30 % couples attending fertility clinics. Where clear diagnosis explaining the decreased or absent fertility cannot be found by the assessment strategies it is labeled as unexplained Infertility. The evaluations do not cover > 25% of reproductive process, the rest is inaccessible to the routine methods of evaluations. Unexplained Infertility is labeled when the assessments show that:
- Wife ovulates and Cervical mucus was fertile in preovulatory phase and no hostility on PCT
- Semen has sufficient number of normal and active progressively forward moving sperms;
- Reproductive passages are patent so there is probability that ovum and sperms meet each other.
The actual phenomenon is after the ovum and sperm contact. The unexplained infertility actually means there are possibilities that:
- The sperms are unable to penetrate the ova meaning lack of natural ability to fertilize (biological barrier) which needs ICSI;
- Fertilization occurred, if so it may be post fertilization failure and not the fertility failure. The possibilities are that:
- The fallopian tubes are unable to nourish and transport the embryo to the uterus;
- The embryo may be reaching uterus but uterus does not accept it (No implantation).
- The embryo may implant but does not grow beyond few days and is expelled before the time of menstruation. Thus conception loss is misinterpreted as menstruation.
It must be appreciated that the management of unexplained cases is by definition empirical. In such cases chances of conceiving without treatment underestimated by the couple and the physician. 30 to 70 % conceive spontaneously within 2 years. In these the factors that prevented the child were temporary and when the conditions were conducive of pregnancy success was achieved. Increasing tendency to delay childbearing for career, social or other reasons put pressure on physicians.
Management Clomiphene citrate is commonly used. It is effective in anovulatory cycles but its use in unexplained cases it is helpful if numerous follicles developme otherwise its use is debatable.
Controlled ovarian hyperstimulation (COH) or super ovulation with gonadotrophins in conjunction with IUI has been a recognized treatment. The likelihood of pregnancy is twofold with FSH and threefold higher with IUI. The combination of the two has a cumulative effect, increasing the odds by a factor of five. It implies that super ovulation with IUI should be offered to couples with unexplained infertility prior to IVF.
The treatment of prolonged or refractory unexplained infertility is IVF but the success rates are low. Assisted Reproductive Technology has simplified the management of such cases.
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