More expensive treatments offered aren’t backed by evidence, the authors say.
A new Australian guideline on unexplained infertility, adapted from the European Society of Human Reproduction and Embryology (ESHRE) 2023 guideline, has been published in the MJA.
The authors, from the Centre for Research Excellence in Women’s Health in Reproductive Life, which is funded by the NHMRC and led by Monash University, say the efficacy, safety, costs and risks of treatment options commonly offered to couples “have often not been subjected to robust evaluation and remain controversial”.
They say their “conservative” recommendations are “likely to reduce costs and burden to both consumers and the health system”.
With 40 recommendations and 21 practice points, the guideline covers diagnosis and treatment of heterosexual couples who fall under the umbrella of unexplained infertility, where investigations exclude problems with ovarian function, fallopian tubes, uterus, cervix and pelvis, and where testicular function, genito‐urinary anatomy and ejaculate are normal.
Definition
The guideline recommends 12 months of adequate attempted conception (at least every two to three days during the fertility window) prior to intervention, though investigation could begin earlier.
Female age is a consideration, male age less so.
Medical, reproductive and sexual history should be obtained from both partners.
A menstrual cycle of 21-35 days lasting up to eight days, with a cycle variation of less than 7-9 days, is considered regular.
Mild male factor infertility precludes a diagnosis of unexplained infertility.
The guideline includes algorithms for determining appropriate diagnosis and treatment.
Diagnosis
There are many tests not recommended as routine.
In women with a regular menstrual cycle, routine ovulation confirmation tests are not recommended. Where needed, the guidelines suggest urinary luteinising hormone measurement, ultrasound monitoring, or mid-luteal progesterone monitoring.
Nor are routine mid-luteal serum progesterone tests for oocyte/corpus luteum quality or endometrial biopsy where there are no other indications of infertility.
Ovarian reserve tests are not needed where there is a regular menstrual cycle.
Ultrasound, preferably 3D, is recommended before going to MRI when investigating uterine structure.
Also not recommended as routine are laparoscopy, tests for antisperm antibodies, thyroid antibodies and other immune conditions, thrombophilia, genetics or genomics tests, vitamin D deficiency, measurement of oxidative stress, or prolactin in the absence of hyperprolactinaemia.
In men it is not recommended to routinely perform testicular imaging, tests for antisperm antibodies, sperm DNA fragmentation, sperm chromatin condensation, sperm aneuploidy, serum hormones, HPV and microbiology when semen analysis is normal.
Postcoital testing and vaginal microbiota testing are also not routinely recommended.
The guidelines do recommend hystero-contrast-sonography and hystero-salpingography for tubal patency (rather than laparoscopy and chromopertubation), and consideration of chlamydia antibody testing. They suggest coeliac disease testing and BMI evaluation in women.
Treatment
The new guideline recommends IUI with ovarian stimulation over IVF, and IVF over intracytoplasmic sperm injection. Tubal flushing with an oil soluble solution is suggested over a water-soluble contrast medium.
Endometrial scratching is not generally recommended. Nor is adjunct oral antioxidant therapy, acupuncture or inositol supplementation.
Psychological support is recommended where needed, along with exercise and a healthy diet.
“Australia’s health model in infertility has evolved to one of competitive commercial organisations that offer higher cost, more complicated services, with a tendency towards earlier intervention, less IUI [intrauterine insemination], more sophisticated testing, and treatment by IVF,” the authors conclude.
“If we are to offer accessible, equitable, cost‐effective fertility services to people who desire a child, we need to align to best practice evidence, and to evaluate current practice in the light of a guideline developed in collaboration with the leading organisation in Europe and adapted to Australian current health systems and practices.”
