A couple investigated for infertility were categorised as ‘unexplained infertility…

A couple investigated for infertility were categorised as ‘unexplained infertility’. (a)
What factors will influence the results of treatment offered? (8 marks) (b)
Summarise the options available to them.

Common mistakes
● Discussing the causes of infertility – there is no need to list the causes of infertility as the
question explicitly demands summarising options for a particular type of infertility – the
unexplained type
● Do not discuss the contributions of every factor involved in infertility
● Taking a history and doing a physical examination is irrelevant. The couple have already
been investigated and categorised as unexplained!
● Details of infertility treatment in general, e.g. ovulation induction regimens in women
with anovulation, in vitro fertilisation with embryo transfer (IVF-ET), etc. These details
are irrelevant to this question
A good answer will include some or all of these points
(a) What factors will influence the results of treatment offered? (8 marks)
● Age of the woman – the younger she is, the better the prognosis
● Previous obstetric history – the chances of a successful pregnancy are greater in women
who have had previous pregnancies compared to those who have not
● How was the diagnosis made – the extent of the various investigations undertaken, i.e.
all subtle causes have been excluded. A more thorough investigation is more likely to
have excluded subtle factors, hence the prognosis is more likely to be better
● Period of waiting/expectant management
(b) Summarise the options available to them. (12 marks)
● Counselling – the first important stage – support – success rate – influence of natural
conception rates superimposed on infertility
● Assisted reproductive techniques:
● Induction of ovulation
● IVF-ET
● Artificial insemination by husband (AIH), artificial insemination by donor (AID)
● All these are expensive – complications – psychological problems with failure
● Adoption

Sample answer
(a) What factors will influence the results of treatment offered? (8 marks)
The outcome of unexplained infertility depends on various factors. These include the age of
the female patient, and the duration and type of infertility. If the woman is over 35 years, the
success of expectant management is poor. Hull et al. (1985) showed that the chances of spontaneous conception are closely related to the duration of infertility and whether it is primary
or secondary in nature. The outcome is better in those with secondary infertility than those
with primary infertility. Where the investigations are more extensive, the pregnancy rates tend
to be much higher, hence the facilities available for investigation and labelling the couple
‘unexplained’ are critical in influencing outcome. The longer the period of expectant management, the better the success rate.
(b) Summarise the options available to them. (12 marks)
The first option for any couple with this diagnosis is counselling and reassurance. The eventual pregnancy rate after 3 years’ expectant management is between 60 and 70 per cent (Hull
et al., 1985). In this option, sympathetic explanation of the diagnosis and the success rate of
expectant management are offered to the couple. A young couple is the most likely to succeed
with this option. This option is frustrating at the best of times, not only to the couple but also
to the physician. For older women the success rate is lower, simply because age has an important effect on spontaneous conception rates.
The next option for the couple is assisted reproduction techniques for infertility. Options
under this category include AIH and IVF-ET. AIH is inexpensive and likely to be acceptable to
the couple. With IVF-ET, superovulation is induced and, after harvesting the eggs, fertilisation
is facilitated in vitro and the fertilised embryo transferred into the uterus. The advantage of this
technique is that fertilisation is guaranteed and extra embryos may be stored for further
attempts. However, this is a very expensive option and one whose failure may be associated
with many psychological problems. This option may be complicated by OHSS, with associated
severe morbidity and sometimes mortality and multiple pregnancies.
The last option for the couple is adoption. Adopting may sometimes remove the anxiety
associated with attempting to conceive and result in a natural conception. Whatever the case,
there is the need to be more proactive in the older than the younger couple. Those with primary infertility have a lower success rate with expectant management than those with secondary infertility. Where the duration of infertility is less than 3 years, expectant management
is associated with an 8 per cent success rate.