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14A - IVF Should Be First-Line Treatment for Unexplained Infertility of Two Years Duration

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from Section III - The Best Policy

Published online by Cambridge University Press:  25 November 2021

Roy Homburg
Affiliation:
Homerton University Hospital, London
Adam H. Balen
Affiliation:
Leeds Centre for Reproductive Medicine
Robert F. Casper
Affiliation:
Mount Sinai Hospital, Toronto
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Summary

Most women conceive within the first 12 months of regular unprotected sexual intercourse. Of the 16% that don’t, around half will conceive without treatment during months 12 to 24 [1]. During those first two years of trying the couple should undergo investigations including semen analysis and confirmation of ovulation and tubal patency (by HyCoSy, HSG or laparoscopy). If all tests return as normal then, by definition, the couple have ‘unexplained’ infertility. Impatience by doctor or patient to ‘do something’ can lead to the use of unnecessary interventions such as ovarian stimulation (OS) (for ovulating women?!) and/or intra-uterine insemination (IUI) (for couples with a normal reproductive tract and sperm function?!) as these are often viewed as softer, more natural treatments. But these are certainly not as natural (or as cheap) as conceiving naturally. A number of studies comparing outcomes of OS or OS-IUI versus IVF to ‘treat’ couples with unexplained infertility unfortunately include patients with 12 to 24 months of trying [2]. Unsurprisingly the OS or OS-IUI success rates are high (and therefore falsely close to IVF). I say unsurprising as the woman was likely to conceive anyway even without OS and/or IUI. For couples with less than 2 years of unexplained infertility, full investigation but no treatment is required.

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Publisher: Cambridge University Press
Print publication year: 2021

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References

National Institute for Health and Care Excellence. Fertility problems: assessment and treatment. Clinical guideline CG156; updated September 2017. www.nice.org.uk/guidance/cg156.Google Scholar
Wang, R, Danhof, NA, Tjon-Kon-Fat, RI, et al. Interventions for unexplained infertility: a systematic review and network meta-analysis. Cochrane Database of Systematic Reviews 2019, Issue 9. Art. No.: CD012692. DOI: 10.1002/14651858.CD012692.pub2.CrossRefGoogle Scholar
Law, YJ, Zhang, N, Venetis, CA, Chambers, GM, Harris, K. The number of oocytes associated with maximum cumulative live birth rates per aspiration depends on female age: a population study of 221 221 treatment cycles. Hum Reprod. 2019;34(9):1778–87.CrossRefGoogle ScholarPubMed
Smith, ADAC, Tilling, K, Nelson, SM, Lawlor, DA. Live-birth rate associated with repeat in vitro fertilization treatment cycles. JAMA. 2015;314(24):2654–62.CrossRefGoogle ScholarPubMed
Noble, M, Child, T. The role of frozen-thawed embryo replacement cycles in assisted conception. Obstet Gynaecol. 2020;22:5768.CrossRefGoogle Scholar

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