Unexplained infertility: a review

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Abstract
Summary. When investigations fail to reveal a cause for infertility, treatment must then be based on possible, but unproven, causes, and since there is a high spontaneous pregnancy rate in unexplained infertility the effect of any treatment is difficult to assess. Such treatment has included correction of anatomical variants such as uterine retroversion and the use of hormonal manipulation during the follicular and luteal phases of the menstrual cycle. Ovum entrapment, occult spontaneous abortion and faults in sperm fertilizing capacity have all been implicated, and it is likely that immunological factors play a substantial role in unexplained infertility. Evidence does not support the use of bromocriptine in the absence of hyperprolactinaemia. Successful treatment by intrauterine insemination is unlikely if there are circulating anti‐sperm antibodies in the partner. Improving cervical mucus by treatment with oestrogens and clearing infections with antibiotics may have a modest place but it is very difficult to show that these treatments have more than a placebo effect. Endometriosis is often missed and the possibility of it having developed after initial investigation warrants repeat laparoscopy after 2 years. Three approaches are currently acceptable in the management of the couple with unexplained infertility: await spontaneous pregnancy, the empirical use of clomiphene and in‐vitro fertilization.