News from ACOG 2018: Unexplained infertility may be an indicator of decreased ovarian reserve even in young women

Despite advances in diagnostic modalities in the infertile couples, the cause of infertility remains largely unexplained in 25% to 30% of couples. The treatment in these couples remains largely empirical.

The result of a small study presented at the ACOG 2018 by, Dr. Andrea Starostanko MD and Dr. Jonathan Ayers MD from Saint Joseph Mercy Hospital Department of Obstetrics and Gynecology, Ann Arbor, MI suggests that even in young women with unexplained infertility (UI) ovarian reserve should be evaluated as part of initial work up.

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They looked at data from 343 nulligravid couples (18-34 years) who were unable to conceive after unprotected coitus for a period of 12 months. The couples underwent tubal patency test, ovulation study and anatomic status by mid-cycle TVUS, comprehensive semen analysis, and assessment of Decreased Ovarian Reserve (DOR) with serum Anti-Mullerian Hormone (AMH).

A cause of infertility was found in 142/343 (41%) couples with anovulation in 30%, anatomic abnormality in 9% and male factor in 6%.  In 201/343 (59%) of couples, no probable cause could be identified.

In these couples with UI, 118/201 women had serum AMH levels below the 95 percentile of age-appropriate value and in nearly 25% of women below the age of 35(53/201), the values were < 1.5.

The researchers concluded that: 

All women with UI should be investigated for ovarian reserve during the initial workup, irrespective of their age

Women who are diagnosed with DOR should seek consultation with a specialist for further treatment options

DOR may also be a harbinger of premature menopause and associated cardiovascular complications  

Abstract

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Subclinical Hypothyroidism linked to unexplained infertility

Women with unexplained infertility (UI) were twice as likely to have a raised TSH level as compared to women who were not able to conceive because of male factor infertility reports the results of a cross-sectional study published in February issue of Endocrine Society's Journal of Clinical Endocrinology & Metabolism.

About 10-30% of the infertile couples have unexplained infertility, defined as an inability to conceive with 12 months of unprotected intercourse with no explainable cause.

Data on the association between subclinical hypothyroidism and infertility is so far limited because of different levels of TSH cutoffs.

For this study, the Harvard based researchers looked at data from large academic health system over a period of 12 years and recruited 239 women with TSH (≤5 mIU/L) and prolactin levels (≤20 ng/ml) within normal range.  Of these women, 187 were diagnosed as UI (study arm), while in 52 women the male partner suffered from azoospermia or severely oligospermia with no other factor diagnosed for infertility (control arm).

After accounting for age, body mass index, and smoking status, it was seen that nearly 27% of women in UI group had TSH ≥2.5 mIU/L as compared to 13% in control group (P < 0.05).

The prolactin levels were comparable between both the groups.

Pouneh K. Fazeli, study’s senior author and a researcher at Massachusetts General Hospital and Harvard Medical School in Boston said, “Since our study shows that women with unexplained infertility have higher TSH levels compared to women experiencing infertility due to a known cause, more research is needed to determine whether treating these higher TSH levels with thyroid hormone can improve their chances of getting pregnant.”

Abstract

Media courtesy: The National Academy of Hypothyroidism

News from American Society for Reproductive Medicine (ASRM) 2016 Scientific Congress— Laparoscopic surgery or ART directly---What comes first in patients with Unexplained Infertility.

Clinical Pearls:

• Both the procedure resulted in pregnancy rate at par with each other, but the researchers advocate doing diagnostic and therapeutic laparoscopy first in patients with unexplained infertility.  

American Society for Reproductive Medicine (ASRM) 2016 Scientific Congress is currently ongoing at (October 15 – 19) Salt Lake City, Utah. Some selected abstract and news from the conference.

It is always an obstetrician dilemma whether to perform laparoscopy first or go for ART in patient diagnosed with unexplained infertility.

 A randomized prospective clinical trial results by Algergawy  A.et al. presented on October 18, 2016 evaluated the outcome of these two approaches.[1]

The study involved a cohort of 423 patients who were diagnosed with unexplained infertility based on normal HSG findings, regular ovulation, normal hormonal profile and normal male partner. These women were randomized into two groups. Women who underwent COH followed by IUI for 3 cycles and then ICSI constituted group 1 (205). The second group (218) consists of women who underwent laparoscopy (Diagnostic and therapeutic).

86 women (41.95%) in the first group conceived within 1 year, 26 cases (12.6%) by IUI. and 60 cases (29.26%) by ICSI.

In the second group, diagnostic laparoscopy revealed multiple pathology like mild to moderate endometriosis, severe endometriosis and hypoplastic fallopian tube. Adhesiolysis, ablation and excision of endometriotic implant was performed. The overall pregnancy rate in group 2 was 84 cases (38.53%). 

Although the pregnancy rate in both group is at par, laparoscopy resulted in better diagnosis of causes of unexplained infertility resulting in better management of cases. It also enabled spontaneous pregnancy in significant number of patients thus avoiding psychological, emotional and physical trauma of ART. It also avoids the many complications of ART like OHSS and multiple pregnancy.

If the patient of unexplained infertility does not conceive after laparoscopy, then ART can always be performed when needed and previous diagnostic laparoscopy facilitates the results of ART.

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[1] http://www.fertstert.org/article/S0015-0282(16)61545-5/fulltext