Evidence-based treatments for couples with unexplained infertility: a guideline
Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org, Practice Committee of the American Society for Reproductive Medicine
Published February 2020Fertility and sterility, 113(2), 305-322
Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org, & Practice Committee of the American Society for Reproductive Medicine (2020). Evidence-based treatments for couples with unexplained infertility: a guideline. Fertility and sterility, 113(2), 305-322. https://doi.org/10.1016/j.fertnstert.2019.10.014
Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org, Practice Committee of the American Society for Reproductive Medicine. Evidence-based treatments for couples with unexplained infertility: a guideline. Fertility and sterility. 2020;113(2):305-322. doi:10.1016/j.fertnstert.2019.10.014
Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org, and Practice Committee of the American Society for Reproductive Medicine. "Evidence-based treatments for couples with unexplained infertility: a guideline." Fertility and sterility, vol. 113, no. 2, 2020, pp. 305-322.
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RRM Academy Synopsis
Treatment for unexplained infertility is empiric, a guideline says
A 2020 guideline from the American Society for Reproductive Medicine says treatment for unexplained infertility is by necessity empiric, which means it starts without a known cause. It drew on 88 studies.
Key Findings
Searching the medical literature, the committee found 88 studies that informed the guideline.
The literature search drew on randomized controlled trials, systematic reviews, meta-analyses, and comparative observational studies, all dated 1968 through 2019.
The committee concluded that when infertility has no explanation, treatment is empiric by necessity.
The committee advises that most couples begin with ovarian stimulation using oral medications plus intrauterine insemination, typically for 3 or 4 cycles, then move to IVF if those cycles fail.
Outcomes of interest included live birth, clinical pregnancy, multiple pregnancy, ovarian hyperstimulation, and ectopic pregnancy.
Interpretation
The summary here describes only the published abstract. The authors report that a task force of experts joined the available evidence with informal consensus, so the advice rests partly on expert agreement. The abstract gives no live birth figures for any treatment.
RRM Context
RRM treats unexplained infertility as infertility with no diagnosis yet, and looks for the cause in both partners. IVF bypasses the reproductive system and leaves the cause unresolved.
Our editorial summary of this paper, not the article's abstract.
Abstract
Objective
To provide evidence-based recommendations to practicing physicians and others regarding the effectiveness and safety of therapies for unexplained infertility.
Methods
ASRM conducted a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1968 through 2019. The ASRM Practice Committee and a task force of experts used available evidence and informal consensus to develop evidence-based guideline recommendations.
Main Outcome Measures
Outcomes of interest included: live-birth rate, clinical pregnancy rate, implantation rate, fertilization rate, multiple pregnancy rate, dose of treatment, rate of ovarian hyperstimulation, abortion rate, and ectopic pregnancy rate.
Results
The literature search identified 88 relevant studies to inform the evidence base for this guideline.
Recommendations
Evidence-based recommendations were developed for the following treatments for couples with unexplained infertility: natural cycle with intrauterine insemination (IUI); clomiphene citrate with intercourse; aromatase inhibitors with intercourse; gonadotropins with intercourse; clomiphene citrate with IUI; aromatase inhibitors with IUI; combination of clomiphene citrate or letrozole and gonadotropins (low dose and conventional dose) with IUI; low-dose gonadotropins with IUI; conventional-dose gonadotropins with IUI; timing of IUI; and in vitro fertilization and treatment paradigms.
Conclusions
The treatment of unexplained infertility is by necessity empiric. For most couples, the best initial therapy is a course (typically 3 or 4 cycles) of ovarian stimulation with oral medications and intrauterine insemination (OS-IUI) followed by in vitro fertilization for those unsuccessful with OS-IUI treatments.
Clinical Guidelines and Standards › Guidelines by Clinical Area › Fertility and Infertility Guidelines · Therapeutics › Ovulation Agents › Selective Estrogen Receptor Modulators · Assisted Reproduction › Outcomes and Effectiveness › Outcomes by Diagnosis
PMID 32106976 32106976 DOI 10.1016/j.fertnstert.2019.10.014 10.1016/j.fertnstert.2019.10.014 Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org et al. 2020, Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org 2020
