Unexplained infertility (a clinical challenge in reproductive medicine)

Unexplained infertility (a clinical challenge in reproductive medicine)

Unexplained infertility is defined as the failure to conceive after 12 months of regular, unprotected intercourse, or after 6 months in women over 35 years of age. Despite significant advancements in diagnostic methods, approximately 10-20% of cases remain classified as unexplained infertility, where routine tests for both partners appear normal.

This diagnosis presents a clinical and psychological challenge due to the absence of a clear underlying cause toward which treatment can be directed.

Diagnostic Assessment:

Unexplained infertility is diagnosed after completing basic investigations, which include:

1- Evaluation of ovulation through ultrasound monitoring of follicles.

2- Semen analysis according to World Health Organization standards.

3- Assessment of the patency of the fallopian tubes.

4- Evaluation of the uterine cavity by ultrasound or hysteroscopy, if needed.

When these elements are normal, the diagnosis is based on exclusion.

Possible Pathological Mechanisms:

Despite the absence of a clear defect, studies point to several subtle mechanisms that may explain the condition, including:

- Subtle disturbances in egg quality.

- Subtle sperm dysfunction (DNA fragmentation).

- Disruptions in the interaction between egg and sperm.

- Impregnation.

- Subtle immunological abnormalities.

Some recent research published in journals suggests that a percentage of these cases may be reclassified later with the development of genetic and functional testing techniques.

Treatment Plan:

Management depends on the woman's age and the duration of delayed pregnancy:

1- Expectant Management.

Suitable for women under 35 years of age with a short period of delayed pregnancy.

2- Ovulation Induction with Intrauterine Insemination (IUI).

This is the first-line option in most cases, especially within 3-6 treatment cycles.

3- Intracytoplasmic Sperm Injection (ICSI).

It is recommended in cases where IUI has failed, the wife is over 38 years old, and there has been more than 3 years of infertility.

Data shows that pregnancy rates in this group are often good when IVF is used, suggesting a minor uterine dysfunction that can be overcome through laboratory testing.

Psychological aspects:

Studies indicate that women with unexplained infertility experience higher levels of anxiety compared to those with a clear organic cause, due to the lack of a direct explanation. Therefore, psychological support is an important part of the treatment plan.

Dr Najeeb Layyous  F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist