Therapy and treatment of Unexplained Infertility
Unexplained infertility does not mean undiagnosed infertility. Unexplained infertility means that all known diagnoses have been eliminated. When a couple is diagnosed with "unexplained infertility", a careful review is conducted of their entire infertility evaluation.
Each test is examined to ensure it was performed correctly and is technically sound. The interpretation and/or conclusion drawn from the results is also examined. Tests with questionable results may be repeated. Further investigation of one or more questionable factors may be conducted. If a thorough review still provides no clues or leads, the next treatment strategy is empirical therapy.
Empirical therapy is treatment based on observation or experience with other infertile couples, rather than on conclusive evidence of what is wrong. The justification for empirical therapy is that it frequently works. Through the use of "Assisted Reproductive Technology" or ART, we join hormonal therapy with a form of artificial insemination (i.e. intrauterine insemination) or IVF.
The purpose of ART is to enhance or bypass as many fertility factors as possible. Sometimes these ART techniques are used to overcome known deficiencies, such as using IVF to circumvent damaged fallopian tubes.
The following are the different levels of treatment based on your age as well as prior history. Each level of treatment involves more time time commitment on your part, but is also associated with a higher probability of pregnancy.
There are Three Levels of Empirical Therapy Treatments
Level 1 includes up to three cycles of clomiphene combined with intrauterine insemination, using 100mg/day for 5 days starting on cycle day 5. Transvaginal ultrasound monitoring will be performed. Usually there will be two or three follicles seen. Follicles are fluid filled sacs which contain the eggs. Once the largest follicle is = 18 mm, hCG is given as a single injection and intrauterine insemination with specially prepared sperm is performed 24 to 36 hours later. It is also possible to schedule the timing of the IUI based on urinary ovulation predictor kits.
Level 2 includes up to three cycles of gonadotropins combined with intrauterine insemination. Gonadotropins (Gonal-F, Follistim, Bravelle, Menopur, Repronex) are started on cycle day 3 and administered daily as injections. Transvaginal ultrasound monitoring is begun after five days of treatment and repeated every 1-2 days until 3-6 follicles reach a size of = 18 mm. hCG is given as an injection to induce ovulation and then intrauterine insemination with prepared sperm is performed 24 to 36 hours later. The sperm preparation is done at the Presbyterian ARTS facility and then brought to our office for insemination.
Level 3 involves the use of IVF. Gonadotropins are administered as in level 2, but with the addition of Lupron injections. Transvaginal ultrasound and blood estradiol measurements are done according to protocol, with hCG being administered when mature follicles are detected. Transvaginal ultrasound-guided follicle aspiration is performed 36 hours later. The eggs from the follicles are fertilized with the husband's sperm in the laboratory. This creates embryos which are then transferred into the uterus 3-5 days later. With IVF, further diagnostic information will be obtained, as we are able to observe the fertilization ability of the sperm, and the embryo development prior to transfer. This information may provide clues to a prior undiagnosed infertility factor.
