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Unexplained Infertility
Assisted reproductive technologies as treatment for unexplained infertility
In vitro fertilization (IVF) has high success in young women with normal ovarian reserve testing and unexplained infertility.
Cervical insemination (CI), where sperm is deposited around the cervix (opening of the uterus, high in the vagina)
Intrauterine insemination (IUI), where sperm is deposited beyond the cervix, right into the uterus (using a catheter - a special tube)
Double IUI (IUI done twice in a single menstrual cycle)
Fallopian tube sperm perfusion (FSP) (pressure injection of sperm in liquid, then sealing the cervix to prevent the liquid leaking back out)
Insemination techniques may be used in natural menstrual cycles, but are usually now accompanied by ovulation induction (use of fertility drugs, also called controlled ovarian hyperstimulation). Ovulation induction can result in ovarian hyperstimulation syndrome (OHSS), which in severe forms can be dangerous.
IUI may have additional adverse effects, as infection could be introduced into the uterus. This dedicated review is important, as the women using insemination for male infertility may be highly fertile (although not necessarily), so the same outcomes may not apply to couples with unexplained infertility.
The 1997 review looked at IUI, combined with ovulation induction. It found that this increased the chances of pregnancy in couples with unexplained infertility.
Many people's first thought in terms of infertility treatment is ART - assisted reproduction techniques (IVF and similar techniques). However, these techniques are very expensive, disruptive and involve the risk of several adverse effects (including increased risk of death or disability associated with preterm birth for babies89). ART clinics can have only a 13-28% chance of resulting in pregnancy or birth, even in the best circumstances with people with quite high fertility. For most people then, especially if they are younger, IVF might be a last resort, not a first step.
With
IVF (in vitro fertilisation), the sperm and eggs are combined in a laboratory (hence the popular term 'test-tube pregnancy'). If an egg or eggs are fertilised, the embryo is surgically transferred into the uterus. Other forms of ART include GIFT (gamete intrafallopian transfer - where the egg and sperm are transferred to the fallopian tubes) and ZIFT (zygote intrafallopian transfer - where fertilised eggs are transferred to the fallopian tubes).
There is not enough evidence on the outcomes of IVF for unexplained infertility. Some of the studies showed no major benefit of IVF or GIFT over intrauterine insemination, with or without ovulation induction. The reviewers concluded that it is possible that IVF results in more pregnancies than other options for unexplained infertility, but this is not certain. More research is needed on birth rates, adverse outcomes and costs.
IVF also can give us clues as to the cause of the infertility. For example, we may see low fertilization rates per egg, or we may see slow embryo development, excessive fragmentation of the embryos, abnormal eggs, abnormal egg shells (zona pellucida), etc.
Tubal flushing (a procedure that may help by 'clearing the path' for eggs to move through the fallopian tubes).
Tubal flushing with oil-soluble contrast media might increase the chances of pregnancy
Tubal flushing (also called hydrotubation) was originally used only as a test for blockages in the fallopian tubes that stop the egg from reaching the uterus.
The traditional methods of tubal flushing have involved using a blue dye and other water-soluble contrast media (WSCM) with laparoscopy, and oil-soluble contrast media (OSCM) for a hysterosalpingogram. The adverse effects of hysterosalpingograms have been reduced with availability of screening with fluoroscopy. Fluoroscopy involves using TV-type screens to view the flushing instead of needing to take x-ray films and develop them.
It was noticed that more women seemed to become pregnant after the test - without any other treatment. A Cochrane review has studied trials of tubal flushing to see if it is useful as a treatment for infertility. The review found that OSCM tubal flushing (particularly with lipidiol accompanied by hysterosalpingogram) increased the chances of pregnancy for couples with unexplained infertility.
Tubal flushing with OSCM also results in less pain for the woman than flushing with WSCM (perhaps because of less chemical irritation from the spread of the fluid into the body). It may be that OSCM is more effective at flushing out debris or dislodging plugs of material from otherwise undamaged tubes: that is, that the tubes are not actually blocked, but there is enough there to get in the way of eggs. However, many infertility specialists and clinics no longer use tubal flushing with hysterosalpingograms in their routine tests investigating infertility. The laparoscopic test with WSCM has become more frequently used instead, as that test can provide extra information. However, what is best as a diagnostic test may not be the best form of tubal flushing to try and increase the chances of pregnancy.
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