Kristen is an ambitious 33-year-old half-Asian half-European graduate student. After seven happy years of marriage with regular sex twice weekly and no birth control, she and her husband have only one pregnancy together, an early miscarriage six years ago, which resulted in a D&C. Since then, there have been no more pregnancies and despite their busy career schedules this year, they really want a baby now. So they decided to take action and seek help from a Reproductive Endocrinologist. She was referred to see me by the recommendation of her sister, who coincidentally, is a RE herself on the East Coast.
Previously, Kristen had been working closely with her OB/Gyn who started some basic testing. Her husband’s sperm was normal (84 million/cc, 90% motility), even though he was still smoking a half pack per day and she reported that some basic hormonal testing done on herself came back all normal, although I don’t have information regarding what exactly was tested. She reported that her periods were regular, but they were a little prolonged in that they came every 35 days or so. Her frustration stemmed from the fact that nothing was wrong with her and her husband. It was compounded by the fact that she had gotten pregnant in the past without a problem. In addition, she had spent several hundreds of dollars already on fertility monitors and test strips. I told her that we had several options at this point. We could do an HSG (hysterosalpingogram), which is an X-Ray test to see if her tubes are open or blocked. We could also give her Clomid to see if it helps the quantity and quality of her ovulation. Or she could keep trying to get pregnant on her own. I advised against choosing this last option. She and her husband discussed it and decided not to be too aggressive yet, so they opted for three cycles of Clomid, without ultrasound monitoring. She did self monitoring with temperature and urine tests and had a positive ovulation test each month. After three months of Clomid, she was still not pregnant, and as we agreed beforehand, we now proceeded to do the HSG.
The HSG revealed two things. Her tubes were clear. Her uterus was normal. This is an example of the classic diagnosis of UNEXPLAINED INFERTILITY. The sperm, ovulation, tubes and uterus show no major problems, yet pregnancy is still not happening. This is the point where many patients are told by their doctors “There is nothing wrong. Keep trying. Goodbye.”, leaving the patient completely frustrated. The proper approach to unexplained infertility is to offer options. Yes, one choice is to keep trying naturally, but for a patient who has already been doing that for seven years, that’s not the best option. Another choice is to help the couple “cheat” to get the odds in their favor. I usually explain it like this.
- A normally fertile couple has a 25% chance of getting pregnant each month.
- A couple with unexplained infertility has about a 2% chance of getting pregnant each month on their own.
- By doing simple intrauterine insemination (IUI) in conjunction with fertility medications, we might be able to bring that up from 2% to 10-20%, depending on how many mature eggs are grown.
- By doing IVF, we can in a single month bring the odds from 2% to about a 40-60% chance of pregnancy.
So rather than patiently accepting a 2% chance each month, Kristen and her husband opted to do a cycle of IUI treatment. She started by taking five days of Clomid followed by two days of injectable gonadotropins. When she returned for her ultrasound, she had two mature follicles growing on her left ovary. She took a shot of hCG to trigger ovulation and insemination was performed two days later. A blood test twelve days later showed an hCG value of 60 IU/L, meaning she was pregnant! She is currently in her second trimester and is due to deliver early next year.
KEY POINTS TO CONSIDER:
- Unexplained infertility is a common diagnosis for infertile couples. It basically means that there is nothing wrong (that we could find).
- There are many good options for dealing with unexplained infertility, including fertility medications, IUI and IVF.
- Had she chosen not to do any treatment, there was still better than a 40% chance that she would be pregnant on her own within the next 5 years.
- It is OK to be proactive and take measures to improve your odds of pregnancy, even when there is nothing wrong found on testing.
By the way, my farewell words to her and her husband when they joyfully graduated from our office at 12 weeks of pregnancy with a single healthy-looking baby was this advice. After the baby is born, she should breast-feed as long as she wanted. THEN, they could try on their own again for six months to a year. If they still weren’t pregnant by then, they could always return for another treatment cycle to get their second baby.