Approximately 20% of couples struggling to get pregnant are told that they have ” “. After examinations and tests, the doctor states there is no known medical reason to explain why they haven’t conceived.
Hearing this, many couples feel a great sense of frustration and think “if everything is okay, then why isn’t it working?”.
A couple should go to a doctor after trying on their own for twelve months, six months for women over 35, and undergo an investigation. There are standard tests for both the woman and the man.
To explain the approach to my patients, I’ve coined the term “SEMS,” which stands for found in ), the woman is likely to be ovulating regularly with a good /egg supply, and a “dye test” (hysterosalpingogram) proves that the fallopian tubes are open. Also, if the doctor suspects the answer may be within the women’s pelvis, then a surgical procedure known as laparoscopy is performed by a ., Eggs, can they Meet, can they Stick, that is to say not miscarry. The term, is used when the quality meets normal standards (no
Laparoscopy is when a surgeon looks into the woman’s pelvis in the operating room with a scope. The doctor may find , a condition responsible for as much as 15-20% of . Sometimes pelvic scarring is identified, which can prevent the transport of the egg into the where it is supposed to meet the and fertilize. If all of these investigations yield normal results, then it is customary to give the couple the diagnosis of “ “.
What happens after the “” diagnosis?
If I reach this diagnosis with a couple, I consider the last part of the SEMS acronym: Stick. The woman may actually be getting pregnant but miscarrying. In fact, it has been estimated that 70% of all pregnancies fail; it just happens so early that the woman is not aware. Recurrent Loss is then the diagnosis.
Unfortunately, checking for all the causes can be costly. A careful review of the patient’s history and that of her family might give some clues. Blood tests are drawn to check for a blood clotting disorder or immune disorder that may be preventing the embryo from implanting in the womb. A hysteroscopy should be performed; an outpatient procedure where the doctor actually looks inside the uterus to see if there is a structural issue inside that may be preventing an embryo from adhering to the wall. After excluding Recurrent Loss, I then give the couple the diagnosis “.”
Even though the couple’s is “unexplained”, treatment to help them have a baby can proceed. Couples with are excellent candidates for insemination therapy if the woman’s egg supply is adequate. Insemination, or IUI, is when is collected, washed, and introduced into the uterus at the time of . Success from IUI can be improved if drugs are used, but the risk of twins or more is greatly increased. It is considered good practice, to limit IUIs for to just three or four attempts. Approximately 30% of couples with will be successful that way.
If insemination fails, a doctor will likely recommend in – IVF. The woman’s ovaries are stimulated with medications and then eggs are collected. is introduced to the eggs and fertilization occurs in the laboratory. The fertilized eggs start to divide, creating more and more cells. When embryos are formed they are placed in the womb. It is interesting that the process of IVF will often explain why the couple was not getting pregnant.
The eggs may be found to be of poor quality when observed under a microscope. Sometimes there is no fertilization of the eggs after the is introduced, raising the question about the quality of the because they failed to penetrate the wall of the egg. In fact, failure of fertilization is so common in couples with that it has been recommended for these couples to inject the into the egg, a process known as Intra-Cytoplasmic Injection- .
It is common in cases with to see embryos that simply do not divide well. When this occurs we feel like we are on the right track in identifying the couple’s problem, but unfortunately, the reason for poor quality embryos is poorly understood.
The good news for couples with is that treatments help them as well as or better than couples with a known diagnosis. Perhaps the best news for couples with is that the problem often resolves spontaneously. Last year, a study was published looking at all the couples who got pregnant on their own after completing treatments such as , successful or unsuccessful, and nearly all of them came from the category “ “. Unfortunately so often the woman’s age, egg reserve, or “biological clock” prevents us from taking a hands-off approach. Couples traveling on this journey are frustrated and stressed, but should take heart and work with their doctors because the prognosis is quite good.