Advanced Treatment with IUI and IVF, In Vitro Fertilization.
During the basic infertility evaluation, your
physician will thoroughly evaluate ovulation, the
status of the fallopian tubes, the uterus, the male
factor, and when necessary, the abdominal and pelvic
cavities for any abnormalities that may prevent the
establishment of a viable pregnancy. Despite the
performance of a thorough basic infertility
evaluation, 20% to 35% of couples will complete
their testing without a definitive diagnosis. These
couples are considered to have “unexplained”
infertility.
Unexplained infertility is often a frustrating
condition, as, while on the surface everything
appears to be normal, conception continues to be
elusive. Once this diagnosis has been made, a couple
has two basic options – proceed to more advanced
testing or start a course of treatment, as there are
several effective treatments for unexplained
infertility.
The simplest treatment for unexplained infertility
consists of
intrauterine insemination (IUI) in a
natural cycle. In this type of treatment cycle, the
woman monitors her follicular development and
impending ovulation, typically using an ovulation
prediction kit. Intrauterine insemination is
performed the day following the detection of the
luteinizing hormone (LH) surge, which is the day on
which ovulation presumably occurs. The chance for
pregnancy with natural cycle/IUI typically ranges
from 6% to 10% per cycle. There is no increased risk
of multiple pregnancy, nor is there any appreciable
increase in the risk of any other types of
complications from this treatment.
A slightly more involved form of treatment for
unexplained infertility is the combination of IUI
with clomiphene citrate. Clomiphene is a medication
that acts directly on the brain and the pituitary
gland, typically resulting in more follicular
development. This medication comes in a pill form
and the typical starting dose is one pill per day
for five days, starting on day 3, 4, or 5 of your
menstrual cycle. Once we determine that you are
responding to the dose of clomiphene that has been
selected, we will ask you to use an ovulation
prediction kit daily. IUI will be performed on the
day following the detection of the LH surge. If you
have had problems in the past using or interpreting
ovulation prediction kits, or if you do not
typically have an LH surge, we may monitor your
follicular development with ultrasound and recommend
a single injection of Ovidrel® or hCG when your
largest follicle is mature in order to cause
ovulation to occur.
If you take Ovidrel®, we will typically perform your
IUI 24 to 36 hours following the injection.
Pregnancy rates following clomiphene/IUI typically
range from 8% to 12% per cycle. In addition, there
is a 5% to 8% risk of multiple pregnancy, although
fortunately almost all of the multiple pregnancies
resulting from clomiphene treatment are twins. As
noted in other sections of our website, clomiphene
can occasionally cause hot flashes, vaginal dryness,
headaches, and/or mood swings. In addition, in up to
40% of patients who take clomiphene, there may be a
significant decrease in the production of cervical
mucus and/or thinning of the uterine lining. In the
event that either of these situations occurs, your
physician will probably recommend that you move on
to an alternative form of therapy.
The next, more aggressive form of treatment for
unexplained infertility combines the use of
gonadotropins (follicle stimulating hormone – FSH,
or human menopausal gonadotropin - hMG) with IUI.
This treatment is more involved, as FSH or hMG are
administered via subcutaneous injection (using a
little needle just under the skin). Patients will
typically start these injections on the second or
third day of their cycle and we will see them in the
office every two to three days for a blood estrogen
level, as well as a vaginal ultrasound to monitor
their progress. The gonadotropins are typically
administered for 6 to 12 days, and when the largest
one or two follicles attain maturity (19 to 20 mm in
size), a single injection of Ovidrel® or hCG is
administered. We will then typically perform IUI on
each of the two subsequent days following your
Ovidrel® or hCG injection. This treatment produces
pregnancy rates of 20-25% per cycle with a multiple
pregnancy rate of approximately 20%. The risk of
triplets or more is approximately 2% of all
pregnancies produced from this form of treatment.
Therefore, out of every 100 women who conceive
following gonadotropin/IUI treatment, approximately
80 will have one baby, 18 will have twins, and 2
will conceive triplets or more. This is why we
monitor you very closely during your stimulation –
to attempt to minimize this risk. Side effects of
gonadotropin therapy include bloating, occasional
mood swings, cyst formation, and temporary weight
gain. There is also a relatively low risk of
developing a condition called ovarian
hyperstimulation syndrome (OHSS), which is
characterized by significant ovarian enlargement,
abdominal swelling, nausea, and occasionally some
shortness of breath. While this condition usually
resolves on its own, we monitor patients at risk for
OHSS very closely to prevent any other
complications.
The final, most aggressive form of treatment for
unexplained infertility is in vitro fertilization.
This treatment is discussed in great detail in other
sections of this web site. Although it is the most
aggressive form of therapy for unexplained
infertility, it is also the most successful form of
therapy. The major advantage of in vitro
fertilization over gonadotropin therapy combined
with IUI, in addition to a significantly higher
pregnancy rate, is a significant reduction in the
risk of high order multiple pregnancy.
In summary, unexplained infertility is a relatively
common cause of infertility. This diagnosis is only
made after a complete basic evaluation for
infertility has failed to reveal a definitive cause
for the couple’s infertility. Despite the lack of a
definitive diagnosis, several effective treatments
are available for unexplained infertility, resulting
in respectable pregnancy rates with a minimum risk
of adverse effects.
