Unexplained Infertility

When the couple’s inability to have children is not detectable, despite the extended screening, then it is assumed that the couple suffers from unexplained infertility. Patients with unexplained infertility are divided in two groups. One group includes patients with no apparent problem and yet cannot conceive. The other group includes patients with some problem which is difficult to be detected. A woman is considered to suffer from unexplained infertility when her ovulation is normal, her fallopian tubes free of fibrosis or endometriosis and has regular intercourse especially at ovulation (10^th – 14^th day of the cycle) for a year without pregnancy. The partner, respectively, should have a normal sperm production. Ten per cent (10%) of all couples with infertility suffer from unexplained infertility although this percentage varies according to the effectiveness of the tests or the type of the technology used. However, the percentage of unexplained infertility is decreased, as the screening gets more detailed.

Possible causes of unexplained infertility.

1. Fallopian abnormalities: An indiscernible disorder in the mechanism with which  the fibria capture the ovum after the ovulation and lead it to the uterus might be present.
2. Luteal phase defect: Luteal is the phase of the cycle after ovulation. If, for some reason, there is a deficiency, it is considered to be luteal phase defect. The corpus luteum produces progesterone, a hormone essential for the preparation of the endometrium to accept the fertilized egg (ovum). The presence of luteal phase defect is checked either by determining the level of progesterone in the blood performed in various days after ovulation, or through an endometrium biopsy.
3. Infections: Some infections are responsible for certain cases of unexplained infertility like mycoplasma or chlamydia which although they are difficult to be detected, they cause infertility.
4. Immunological factors: It is possible that the female immune system may react to the sperm by destroying it, immobilizing it or causing it to agglutinate. In addition, some women develop an immunological reaction to the outer shell of the egg blocking the sperms.
5. Inability of the sperm to penetrate the egg: Although some men have a normal sperm count, it cannot fertilize the egg. The only diagnosis for this case is in vitro fertilization and Intracytoplasmic sperm injection (ICSI).
6. Uterus: Some women present abnormalities in the endometrium which prevent the implantation of the fertilized egg. A vaginal ultrasound may confirm the diagnosis. The endometrium of a few infertile women remains extremely thin, probably due to insufficient blood supply or due to insufficient oestrogen receptors in the endometrium cells. This remains a difficult problem to be dealt with and the treatment remains basically simple by prescribing low doses of aspirin, or high doses of oestrogen.
7. Abnormal eggs: A very small percentage of unexplained infertility has to do with the production of abnormal eggs. These may be disfigured in shape or have chromosomatic disorders (especially in older women).
8. Unruptured follicles(Luteinized Unruptured Follicles LUF Syndrome): In some cases, although the eggs are normally produced and matured they remain in the follicle because they cannot disrupt it.
9. Psychological factors: Studies on various groups of infertile couples have shown an inability of agreement on the significance of the psychological factor as a cause for infertility. Emotional disorders play, no doubt, a role which is justified by the fact that the whole hormonal cycle with its delicate regulation is controlled by the brain. However, this is an area in need of further investigation.

Has something been left out? All the previously mentioned tests should be reconsidered for the unexplained infertility to be confirmed. Some of them may even be repeated.                                                                                                                      

How is unexplained infertility treated? There is always the possibility of a pregnancy without any treatment. If no disorder is detected, the possibility of a pregnancy in three years is one in three cases. Treatment helps, no doubt, the increase of the rate of conception sooner. Treatment of the luteal phase defect is as controversial as is its diagnosis. Clomiphene citrate (Clomid) may increase the FSH secretion improving the quality of the follicle (as well as the corpus luteum developed in it). Treatment with progesterone (either in injection or vaginal suppositories) helps the luteal phase defect as well. Many patients worry that infertility may not be successfully treated unless the causes are detected. Fortunately, today, this is not so, as technology has developed more in therapy rather, than in diagnosis! Anyway, most couples with infertility do not concern themselves so much with the causes as with the solution of their problem. They want to have a baby!Today, with the help of the assisted reproduction technologies (ART), the possibility of a pregnancy is very high. Intrauterine insemination (IUI) with mild ovarian stimulation is the simplest method of treatment by increasing the possibility of the spermatozoa meeting the egg, whereas with fallopian tube sperm perfusion (FSP) is a another form of insemination which forces the sperm to be pushed in the fallopian tubes and the pouch of Douglas, that is at the site where eventually fertilization of the egg takes place. A more advanced method of insemination is intrautero – tubo – peritoneal insemination (IUTPI), which is only performed in our Unit with very promising results.  Other patients may be treated with In Vitro Fertilization (IVF), or Micromanipulation (ICSI), where Fertilization of the ovum (egg) is performed in a laboratory and the embryo is then transferred in the uterus after two or three days.