Unexplained subfertility: diagnosis and management

Abstract

Key content Unexplained subfertility is diagnosed when standard investigations (tests for ovulation, tubal patency and semen analysis) are all normal. Between 30% and 40% of subfertile couples fall into this category. In some couples, unexplained subfertility may result from subtle undetectable factors; in other couples, it may be associated with a genuine absence of any abnormality. There is currently much controversy about the selection of appropriate management options for such couples, especially following the National Institute for Health and Care Excellence (NICE) guideline published in 2013. Therefore, a clear understanding of the available evidence is essential for the management of couples with unexplained subfertility. The potential contributing factors, diagnosis and management of unexplained subfertility are discussed. Learning objectives To summarise the available recent evidence and help the reader obtain a clear understanding of the continuing debates in this field. To help clinicians in counselling couples with unexplained subfertility. Ethical issues Should couples be advised to try to conceive naturally for 2 years (regardless of their age) before they are offered treatment, even though fecundity declines with age? What does the evidence suggest should be the first line of management for couples with unexplained subfertility: intrauterine insemination or in vitro fertilisation?

Irresponsibly Infertile? Obesity, Efficiency, and Exclusion from Treatment

“…The guidelines recommend that women aged 40–42 should be offered one cycle of IVF. The recommendations for specific diagnosable causes of subfertility differ from those relating to unexplained subfertility, which is reported to affect somewhere between 10 and 40% of couples with subfertility [ 3 , 23 , 37 ]. For much of this paper I will be concerned with treatment for unexplained subfertility, for which IVF is the main available intervention.…”

Meiosis interrupted: the genetics of female infertility via meiotic failure

“…Egg quality decreases with increasing maternal age, but other causes of poor egg quality likely exist (Lindsay & Vitrikas 2015, Ruebel & Latham 2020. Despite being of an optimal maternal age and the absence of reproductive pathology, many women have difficulty conceiving (Nandi & Homburg 2016) or endure recurrent idiopathic miscarriage (El Hachem et al 2017). Why some women face exceptional difficulty conceiving and carrying a pregnancy to term is poorly understood.…”

Unexplained infertility; How far laparoscopy can disclose the causes

“…It accounts for nearly 40%of female infertility and 8% to 28%of infertility in couples. The reported incidence of unexplained infertility varies according to the age and selection criteria in the study population [4] . Many couples with a provisional diagnosis of unexplained infertility will subsequently conceive spontaneously; the spontaneous pregnancy rate in couples with unexplained infertility has been reported as 2%to 4% per menstrual cycle.…”

“…After 12 months of unsuccessful attempts, 50% will conceive in the following 12 months and another 12% after 24 months. (Box1) [3,4] .…”