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Around Suannan / Post Doctoral Fellowship in Reproductive Medicine: The Unexplained Infertility
« เมื่อ: พฤษภาคม 07, 2025, 04:46:23 pm »
Unexplained Infertility- Is this unexplained or unexplored? Don't we all agree that there is a lot of explanation that is needed when it comes to explaining even the wordings of unexplained infertility in a program like the Fellowship in Reproductive Medicine. It could be the mysteries of the unexplored words. So let hope rise and darkness tremble as we delve ourselves deeper into this interesting topic. Is infertility unexplained then? Is it a controversial diagnosis?
We can say something as unexplained infertility only after a full and complete fertility evaluation of both the male and female partners. So incomplete evaluation definitely makes a fertility specialist say that it is unexplained. Is this correct? No. So the diagnosis of unexplained infertility is that one of elimination. But the point that we should really ponder is, are we able to diagnose everything to eliminate it? In other words, do we have the modalities to diagnose all the causes of infertility, and, finally, label the couple as unexplained infertility when we are not able to find the problem. There's a lot to be said about the nomenclature of this condition. So here we have one now asking what are the other words for unexplained? Unexplored, undiscovered, inexplicable, unidentified, unfamiliar, strange, un-apprehended, unascertained is the answer that we get in the Thesaurus.
But unexplained infertility, the very existence of this terminology, is it doubtful? So again, we come back thinking whether unexplained infertility is, as simple as a nomenclature as it seems to be. And the other enigma is that you tell the patient that everything is fine but still she's not getting pregnant. And it's very important to clarify, therefore, on that unexplained infertility is not the same as idiopathic female or male infertility. Idiopathic female infertility may occur when a woman isn't ovulating regularly or normally, but it's unclear why ovulation isn't happening when it should.
here's a subtle difference between, idiopathic and unexplained. Some factors yet known to infertility experts. Why do we still have this entity of unexplained infertility? That is because the experts are not able to explain certain conditions. It may be that it is completely unknown because it's completely unknown to the medical professionals at any point of time. And infertility is a very ongoing subject where every day there are hundreds and thousands of researchers and papers coming up, and, researchers and scientists and clinicians are coming up with new modalities and new definitions. Therefore, it all just means that there's so much more in infertility to know about, and there is definitely the scope for unexplained infertility. So unexplained infertility, therefore, is not just in your head, and it cannot be caused by trying too hard or stress. It is very insensitive when doctors, just dismiss infertility if a clear problem can't be found. We can't tell the patient, oh, there's no problems or there's no reason to be infertile.
“When the world says give up, hope whispers try one more time.”
Several key variables that include age, infertility history, treatment history, costs, and risks should be considered in selection of a suitable treatment plan for each of these couple. The causes of unexplained infertility. It is possible to draw a long list of putative and subtle causes of infertility, but we are not certain about many of them, and many have been found in couple with normal fertility also, and few of these conditions when we really find are actually treatable. This arises because there are subtle undetected defects in the reproductive process which modern science has still not been able to understand.
The conception can just be delayed by chance alone because the couple's fecundity may be on the lower side of the normal distribution. And many steps are not routinely evaluated or it may be unavailable because of various reasons. So then, Infertility is a disease, just like diabetes or cancer. And when we tell someone that just relax and you'll get pregnant, it's the same as telling someone with cancer to relax and you'll be healed. It's very important for clinicians as well as patients to understand that infertility is a real entity which has to be addressed even if it is unexplained.
The possible causes could be:
• Disturbance in endocrine balance
• Immunology
• Genetic
• reproductive physiology
There could be a defect in the fertilization ability of the sperm. The sperm head defects affecting transport through the cervical mucus could be another factor. Bidirectional tubal motility, which is detrimental to the process of fertilization, could be a cause. And finally, defective oocytes, especially in aging patients.
Was the infertility evaluation complete? Was it performed correctly, meaning using the right time, the using the right methodology, and, explaining to the patients what to expect? And finally, has it been interpreted appropriately? These are the questions that we should be asking ourselves when we are in evaluating a case of infertility.
In between these two extremes are those tests which are inconsistently correlated with pregnancy, that is the postcoital test, zona free hamster penetration test, cervical mucus penetration test, hysteroscopy, thyroid testing, prolactin measurements, and BBT. So unexplained infertility, again, to stress, does not mean that there is no physical explanation for infertility, but it means that the medical tests have not yet identified the cause, provided we have done all the relevant tests. It is deleterious to omit Hyster laparoscopy completely in patients with assuring HST if we have a suspicion of minimal endometriosis or any tubal pathology. The findings at laparoscopy in patients with presumptive diagnosis of unexplained infertility, here we can say most of it is endometriosis that is seen endometriotic spots. So this could be a major cause because endometriosis these spots may not be detected even on ultrasound.
Expectant management is the first line of treatment in many of these cases. Tubal flushing or perturbation, ovulation induction drugs like clomiphene citrate, aromatase inhibitors, and gonadotrophin, superovulation with IUI, fallopian tube, sperm perfusion, and finally, IVF and ICSI. Expectant often the first line of treatment, and it plays an important role, especially if there are limited source settings, the woman is relatively young, and the period of infertility is short. This also includes lifestyle changes for both the partners, and they should be counselled to achieve a normal BMI, reduced caffeine, and also alcohol intake, and, of course, stop nicotine. The prognosis often with expected management is good if the duration of infertility is less than two years even without therapy. But then the female partner should not be over 35 years of age. And on the other end of the spectrum is the worst prognosis when the duration of infertility is more than three years and also the female partner is more than 35 years old. The treatment, actually, by definition, it's of course empiric. And it does not address a specific defect or functional impairment and the disease is not defined. So, it is dependent on availability of resources, patients, age, and duration of infertility.
And the standard protocol is to progress from simple to complex. And with an eye on the balancing the effectiveness against the cost and also the side effects. Now how does IVF compare with expectant management? The Cochrane database said there was a higher pregnancy rates in IVF compared to expectant management. Live birth rates and women with single cycle IVF are also significantly higher than with expectant management.
ICSI should be the first line therapy in IVF in unexplained infertility, especially in women over 35 years. Now let us have a look at some of the studies. This is a randomized control trial to determine optimal infertility treatment in older couples, the 40 and over treatment trial, 40, in the fertile sterile journal fertility sterility journal of 2014. The conclusion was in older women with unexplained infertility, comparing the treatment initiated with two cycles of controlled ovarian hyperstimulation and IUI versus immediate IVF demonstrated superior pregnancy rates with fewer treatment cycles in the immediate IVF group. Another study about in vitro fertilization for unexplained subfertility, it was a review. (covered in detail with the Fellowship in Reproductive Medicine in India’s curriculum)
Medline Academics has been educating students for Post Doctoral Fellowship in Reproductive Medicine for many years and still continues to be the most sought-after medical course in Reproductive Medicine under the guidelines of Padma Shri Prof. Dr. Kamini Rao. The Fellowship in Reproductive Medicine (FRM), Fellowship in Embryology (FIE), their fellowship courses are one of the best in the country for which they offer Hybrid Mode of Education: The students can attend all online modules at their convenient place while the Live Contact Program classes are every week covering almost all top demanded topics in the subject. Students have to complete their Simulation training at Bangalore centre which is having world standard in providing simulation training before the students can handle actual patients. It has the best Simulation Training and excellent training equipment of this training institution.
Dr. Kamini Rao hospitals also provide clinical attachment if the students would wish to undertake the clinical attachment in Bangalore under the supervision of Padma Shri Prof. Dr. Kamini Rao. This healthcare unit also provides Best IVF Treatment Centre in Bangalore with top experts in Reproductive medicine. This healthcare is unique in providing both treatment and affordable and quality practical training for doctors aspiring to excel in the reproductive medicine.
We can say something as unexplained infertility only after a full and complete fertility evaluation of both the male and female partners. So incomplete evaluation definitely makes a fertility specialist say that it is unexplained. Is this correct? No. So the diagnosis of unexplained infertility is that one of elimination. But the point that we should really ponder is, are we able to diagnose everything to eliminate it? In other words, do we have the modalities to diagnose all the causes of infertility, and, finally, label the couple as unexplained infertility when we are not able to find the problem. There's a lot to be said about the nomenclature of this condition. So here we have one now asking what are the other words for unexplained? Unexplored, undiscovered, inexplicable, unidentified, unfamiliar, strange, un-apprehended, unascertained is the answer that we get in the Thesaurus.
But unexplained infertility, the very existence of this terminology, is it doubtful? So again, we come back thinking whether unexplained infertility is, as simple as a nomenclature as it seems to be. And the other enigma is that you tell the patient that everything is fine but still she's not getting pregnant. And it's very important to clarify, therefore, on that unexplained infertility is not the same as idiopathic female or male infertility. Idiopathic female infertility may occur when a woman isn't ovulating regularly or normally, but it's unclear why ovulation isn't happening when it should.
here's a subtle difference between, idiopathic and unexplained. Some factors yet known to infertility experts. Why do we still have this entity of unexplained infertility? That is because the experts are not able to explain certain conditions. It may be that it is completely unknown because it's completely unknown to the medical professionals at any point of time. And infertility is a very ongoing subject where every day there are hundreds and thousands of researchers and papers coming up, and, researchers and scientists and clinicians are coming up with new modalities and new definitions. Therefore, it all just means that there's so much more in infertility to know about, and there is definitely the scope for unexplained infertility. So unexplained infertility, therefore, is not just in your head, and it cannot be caused by trying too hard or stress. It is very insensitive when doctors, just dismiss infertility if a clear problem can't be found. We can't tell the patient, oh, there's no problems or there's no reason to be infertile.
“When the world says give up, hope whispers try one more time.”
Several key variables that include age, infertility history, treatment history, costs, and risks should be considered in selection of a suitable treatment plan for each of these couple. The causes of unexplained infertility. It is possible to draw a long list of putative and subtle causes of infertility, but we are not certain about many of them, and many have been found in couple with normal fertility also, and few of these conditions when we really find are actually treatable. This arises because there are subtle undetected defects in the reproductive process which modern science has still not been able to understand.
The conception can just be delayed by chance alone because the couple's fecundity may be on the lower side of the normal distribution. And many steps are not routinely evaluated or it may be unavailable because of various reasons. So then, Infertility is a disease, just like diabetes or cancer. And when we tell someone that just relax and you'll get pregnant, it's the same as telling someone with cancer to relax and you'll be healed. It's very important for clinicians as well as patients to understand that infertility is a real entity which has to be addressed even if it is unexplained.
The possible causes could be:
• Disturbance in endocrine balance
• Immunology
• Genetic
• reproductive physiology
There could be a defect in the fertilization ability of the sperm. The sperm head defects affecting transport through the cervical mucus could be another factor. Bidirectional tubal motility, which is detrimental to the process of fertilization, could be a cause. And finally, defective oocytes, especially in aging patients.
Was the infertility evaluation complete? Was it performed correctly, meaning using the right time, the using the right methodology, and, explaining to the patients what to expect? And finally, has it been interpreted appropriately? These are the questions that we should be asking ourselves when we are in evaluating a case of infertility.
In between these two extremes are those tests which are inconsistently correlated with pregnancy, that is the postcoital test, zona free hamster penetration test, cervical mucus penetration test, hysteroscopy, thyroid testing, prolactin measurements, and BBT. So unexplained infertility, again, to stress, does not mean that there is no physical explanation for infertility, but it means that the medical tests have not yet identified the cause, provided we have done all the relevant tests. It is deleterious to omit Hyster laparoscopy completely in patients with assuring HST if we have a suspicion of minimal endometriosis or any tubal pathology. The findings at laparoscopy in patients with presumptive diagnosis of unexplained infertility, here we can say most of it is endometriosis that is seen endometriotic spots. So this could be a major cause because endometriosis these spots may not be detected even on ultrasound.
Expectant management is the first line of treatment in many of these cases. Tubal flushing or perturbation, ovulation induction drugs like clomiphene citrate, aromatase inhibitors, and gonadotrophin, superovulation with IUI, fallopian tube, sperm perfusion, and finally, IVF and ICSI. Expectant often the first line of treatment, and it plays an important role, especially if there are limited source settings, the woman is relatively young, and the period of infertility is short. This also includes lifestyle changes for both the partners, and they should be counselled to achieve a normal BMI, reduced caffeine, and also alcohol intake, and, of course, stop nicotine. The prognosis often with expected management is good if the duration of infertility is less than two years even without therapy. But then the female partner should not be over 35 years of age. And on the other end of the spectrum is the worst prognosis when the duration of infertility is more than three years and also the female partner is more than 35 years old. The treatment, actually, by definition, it's of course empiric. And it does not address a specific defect or functional impairment and the disease is not defined. So, it is dependent on availability of resources, patients, age, and duration of infertility.
And the standard protocol is to progress from simple to complex. And with an eye on the balancing the effectiveness against the cost and also the side effects. Now how does IVF compare with expectant management? The Cochrane database said there was a higher pregnancy rates in IVF compared to expectant management. Live birth rates and women with single cycle IVF are also significantly higher than with expectant management.
ICSI should be the first line therapy in IVF in unexplained infertility, especially in women over 35 years. Now let us have a look at some of the studies. This is a randomized control trial to determine optimal infertility treatment in older couples, the 40 and over treatment trial, 40, in the fertile sterile journal fertility sterility journal of 2014. The conclusion was in older women with unexplained infertility, comparing the treatment initiated with two cycles of controlled ovarian hyperstimulation and IUI versus immediate IVF demonstrated superior pregnancy rates with fewer treatment cycles in the immediate IVF group. Another study about in vitro fertilization for unexplained subfertility, it was a review. (covered in detail with the Fellowship in Reproductive Medicine in India’s curriculum)
Medline Academics has been educating students for Post Doctoral Fellowship in Reproductive Medicine for many years and still continues to be the most sought-after medical course in Reproductive Medicine under the guidelines of Padma Shri Prof. Dr. Kamini Rao. The Fellowship in Reproductive Medicine (FRM), Fellowship in Embryology (FIE), their fellowship courses are one of the best in the country for which they offer Hybrid Mode of Education: The students can attend all online modules at their convenient place while the Live Contact Program classes are every week covering almost all top demanded topics in the subject. Students have to complete their Simulation training at Bangalore centre which is having world standard in providing simulation training before the students can handle actual patients. It has the best Simulation Training and excellent training equipment of this training institution.
Dr. Kamini Rao hospitals also provide clinical attachment if the students would wish to undertake the clinical attachment in Bangalore under the supervision of Padma Shri Prof. Dr. Kamini Rao. This healthcare unit also provides Best IVF Treatment Centre in Bangalore with top experts in Reproductive medicine. This healthcare is unique in providing both treatment and affordable and quality practical training for doctors aspiring to excel in the reproductive medicine.