Unexplained Subfertility

1. UNEXPLAINED
SUBFERTILITY

2. References
• NICE Clinical Guideline, Fertility problems: Assessment and
Treatment, 20 February 2013
• Unexplained subfertility: Diagnosis and Management, TOG, 14
August 2015
• Unexplained subfertility STRATOG

3. Assessments

4. •Defined as failure to achieve conception
after a 12 month attempt to conceive has
been made through unprotected vaginal
sexual intercourse.
•Diagnosis of exclusion
•Prevalence 15%, ranges between 7-21%

5. Epidemiology
• Fecundability for humans 15-20%
• Affected by age and time
• Women < 36 years old, the cumulative probability of pregnancy is
approximately 80% at 12 months of trying, and 90% by the end of 2
years.
• Women > 36 years old, less than 50% will be pregnant by 12 months.
• Graph

6. •Incidence of infertility worldwide is about 14%
• woman’s ability to conceive is affected by
duration of trying, her age and causation.
•In women under the age of 36, infertility is
defined as inability to conceive after 1 year
when no obvious causative pathology has
been identified.
•If a couple is > 36 years old, the couple should
be referred much sooner.

7. • Relative incidence of unexplained infertility depends on how
carefully other causes are investigated.
• In the UK, the incidence of ovulatory disorders is about 15%.
• Tubal disease and male factor infertility are becoming more
prevalent because of the increasing number of chlamydia
infections.
• Male factors now account for up to 40% of cases of infertility
• In about 20% of cases both male and female factors may
coexist

8. • Figure 2

9. Initial evaluation – Primary Care
• Counseling services
• Detailed history and examination
• NSAIDS use
• Update cervical smear history
• Rubella immunization history
• Screening for chlamydia
• Consider underlying conditions or systemic disease
• Provide coital and general lifestyle advice

10. Initial Evaluation – Secondary and Tertiary care
Male fertility declines with age
Recommended that serum analysis be performed at a regional dedicated
andrology lab using WHO (2010) reference values
Semen analysis
- is not an accurate test for fecundability (unless there is azoospermia or
cryptozoospermia.
- a guide for minimum standards required to obtain pregnancy in 12 months of
unprotected sexual vaginal intercourse.
- an abnormal first test warrants repeat semen analysis after 3 months
In azoospermia, crytozoospermia and severe oligozoospermia, a detailed history
should be obtained to rule out reversible causative factors.
- If a cause is found, it should be treated before repeating after 3 months
- If there is demonstrable recovery, the semen analysis should be repeated every 3
months until back to normal parameters. Couple try again for at least 6 months
before a diagnosis of unexplained infertility is made.

11. Initial Evaluation – Secondary and Tertiary care
• Tests of ovulation and ovarian reserve
• Ovarian reserve testing in tertiary care
• Woman’s age – initial predictor – ASFR
• ovarian reserve tests
• Tests of tubal patency

12. Possible aetiologies
• Subtle abnormalities in oocyte and/or sperm function
• Defective endometrial receptivity
• Subclinical endometriosis
• Nutritional factors
• Undiagnosed or untreated celiac disease
• Immunological factors
• Poor ovarian reserve can masquerade as unexplained subfertility

13. Treatment of unexplained infertility
• Treatment options
• Counseling
• Expectant management
• Medical management
• Assisted reproductive techniques (ART)