- [Dr. Scott] What is unexplained infertility?
Welcome to Fertile Minds today.
I'm Scott Salisbury. I'm a fertility specialist
with QFG in Brisbane. And today we are going to explain,
unexplained infertility as well as we can explain anything.
So firstly, we should start with a, a definition
and it's a difficult definition
cause it's changed over the years.
Essentially, when someone presents
with difficulty in falling pregnant,
we look at a number of tests to try and establish what
the underlying cause is, we would look firstly,
to see what sperm quality is like,
whether ovulation is occurring,
whether there is tubal patency and in modern day definitions
that's also included investigations
for things like ovarian reserve
and a test of things like endometriosis.
When we don't find an obvious cause we label
that unexplained infertility.
So it's an unfortunate diagnosis because a lot
of people want us to find a cause and be able to
put a bandaid on that or treat that appropriately.
And that's just not the case with unexplained infertility.
Now of course unexplained infertility
doesn't mean there's not a cause
but in our basic workup, we haven't established that.
But it also means, very encouraging, that a good number
of people will be able to achieve a pregnancy
by their own accord without any treatment.
So I do encourage people to continue
in the old fashioned manner
and good pregnancy results were obtained
over the ensuing year or two. Of course
most people don't want to wait that long
in order to achieve a pregnancy.
And I guess from that perspective, people are asking
about whether they should go and see a fertility specialist.
And when that should occur is always a difficult dilemma.
But I always say when people start
to be worried is when people should present.
Typically that would be 12 months of trying in someone
under the age of 35 and someone over the age of 35
perhaps it may be around the six month mark.
Equally, if there was any other obvious cause
like infrequent periods, et cetera, or previous surgery
that may have compromised their fertility,
then obviously earlier presentation would be appropriate.
Having established that the diagnosis
is unexplained infertility where there's been
no obvious cause in other words, a diagnosis of exclusion
we do run through the process of conception
and that may sound a silly thing to do.
But in fact, if you think about it, logically
we can establish whether people ovulate
but we can't establish whether those eggs
are actually retrieved for, by the tube.
We can time intercourse appropriately,
But we don't know how often that sperm actually moves
up through the cervical mucus
through the uterus and actually finds the egg.
I mean, this is an environment where they're
in the dark, they're microscopic,
and they may never meet each other.
And even if there is this chance meeting
how often do they fertilise the egg?
Because we know with IVF only
about 60% of eggs fertilise, and then
of course the embryo has gotta be normal and that's
very much an age dependent thing where with increasing age
there's an increasing rate of abnormalities.
So it's important to convey all that.
And also the last part of the process
where the embryo is transported back
to the uterus is also an important one.
So they're factors that we don't truly understand.
So part of our strategy in managing
or treating unexplained infertility involves
in playing the probability game
by boosting those parameters.
So in other words, we may look at helping you with timing.
Typically people would have done temperature charts
or checking mucus which I don't really think
are a useful way of doing it. They're a very low key way
of doing for people. It's not that it's not useful,
it's just that I think a lot of people find that stressful.
Certainly urine detection kits, so-called
ovulation predictor kits are a useful adjunct, but again
they're expensive and they often conjure
up lots of anxiety in people through their usage.
In the medical sense, we use blood tests and
or ultrasounds done vaginally and even sometimes
trigger injections to optimise the timing of intercourse.
And, and that's quite a commonly used strategy
to be reassuring to people they're on the right track
of what they're doing naturally.
Often we go beyond the realm of that
and we look at boosting ovulation and by boosting ovulation
I mean make the cycle hormonally more correct
or in some circumstances increasing the number
of eggs you produce. They would typically be done
with tablets like Clomiphene or Letrozole.
These are anti oestrogen tablets that increase the number
of eggs that you produce
and also strengthen various facets of your cycle.
Typically they would have no side effects
but minimal side effects like headache, hot flushes
sometimes mood disturbance can be experienced.
But of course the biggest concern is that there is a risk
of multiple pregnancy with these medications.
While small and often people are desirous
of multiple pregnancy, these a very high risk events
and the risk of preterm labour, miscarriage, et cetera,
are all increased. So they're certainly
not our desired option in the short term.
We'll often also consider injections
like we use with IVF in the form of FSH.
These are daily administered injections.
And whilst the evidence for both using these tablets
and indeed FSH in unexplained infertility
is not well-proven, there are strategies
that, that make people feel like they're doing something
proactive towards an end point.
We'd sometimes also entertain the possibility
of doing an insemination.
And, and that's where we collect sperm from the partner,
we prepare the sperm and we actually place it
into the uterine cavity as a way
of getting sperm up closer to the action point.
All those strategies are again
just increasing the probability, but still we don't know
in that equation whether egg is being picked up,
whether the egg is being fertilised,
whether that egg is normal, whether it is progressing,
whether it's making its way back to the uterus.
So that's where we might entertain the possibility
of doing IVF. And IVF really is a way
of increasing that probability quite dramatically
because typically we'd get 10 to 12 eggs with IVF,
you know a year's worth of releasing one egg a month
and we'd see firsthand whether they'd fertilise,
we follow their progress in the laboratory.
And we watch their growth to five days.
We still don't strictly know whether they're normal
although there's been big advances in that field as well
in terms of genetically testing.
And sometimes we even genetically test couples
in advance so that to try and predict whether
there are higher chance of having a child with an anomaly.
But again, on this occasion we've got a fertilised egg
that's grown appropriately and in the right place.
So we've gone a long way to making sure
we've got as many facets correct.
So it's still really important in that timeframe
that people are encouraged to keep on trying normally
because we've all heard the stories
of people that conceive in between treatment strategies.
It's also a time to reflect on, on lifestyle modifications
the amount of alcohol, the amount of coffee you have,
optimising weight, making sure you're taking
all the appropriate supplements
and actively engaging people in the process.
And I think that's really important
because everyone's an individual again
and here we are suggesting these things
but by no means are we pushing the bar on them.
And what I mean by that is that at the end
of the day choice of what treatment strategy is utilised
is, is entirely up to you.
We're just here to offer the suggestions
and for you to choose.
And some people for various reasons because of age,
because of religious, moral situations
will push one treatment more than another.
And that's completely acceptable.
It's all about trying to increase the probability
of trying to conceive.
So just in summary, unexplained infertility
is a difficult one because people
do want us to identify a cause
and want us to correct that cause,
but here is a situation where we can't always
identify a cause and it's about
picking a strategy that will further
enhance their chances of pregnancy
in their pursuit of having a baby.
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Thank you.