Unexplained subfertility is diagnosed when you have been having regular unprotected intercourse for more than twelve months, and initial investigations have not shown any major cause of infertility.  This can be a rather frustrating diagnosis to be given, but be reassured that your chances of a pregnancy eventually are better than if we find a major problem.  It may be that if we look harder and do further tests, we find a explanation, such as mild endometriosis, subtle ovulation problems, or factors in the cervix that are interfering with your fertility.  

Looking for endometriosis with laparoscopic or keyhole surgery is a reasonable option, as mild to moderate endometriosis can be treated at the same time as the diagnosis, with a subsequent boost in your fertility (see below for further information).    Tests for cervical problems and subtle ovulation disorders are available but involve invasive techniques that delay your ability to keep trying for a pregnancy.   Furthermore, we do the same things to treat your subfertility whether these tests are normal or abnormal.  I therefore do not recommend these tests.  

The options for treatment of unexplained subfertility are as follows:

1.  Keep trying to conceive naturally
A fertility specialist can advise you of the chances of this occurring in your individual circumstances.

2. Surgery (laparoscopy and hysteroscopy) for diagnosis and treatment endometriosis.  
If we find and then treat mild to moderate disease this doubles your chances of pregnancy per month in the few months after surgery.  

Allows you to continue trying naturally for a pregnancy with a boost to your natural chances.

Disadvantages: Invasive procedure with the need to take 2-7 days off work.  Complications of surgery can occur.

3.  Stimulated insemination
Low doses of hormonal treatment to improve the quality of ovulation, combined with artificial insemination to further boost the chances of pregnancy and bypass any cervical problems that may be present.   The chances of a pregnancy in your situation using this technique can be estimated by a fertility specialist.  

Advantages:  More natural than IVF, lower doses of hormones.

Disadvantages: High chance of multiple pregnancy.  Approximately 15% of pregnancies with this technique are twins, and 0.5% are triplets.  This compares to  0.5-1% chance of twins with natural conception or IVF with single embryo transfer.   The time commitment and monitoring for this technique is quite similar to IVF, with a lower chance of pregnancy.  

4. IVF
Higher doses of hormonal treatment given to try to get 8-15 mature eggs to grow at once.  The eggs are then collected with a needle under local or general anaesthetic and then mixed with the sperm in the laboratory.  Embryos are then grown in the laboratory for usually five days and then transferred into the uterus.  Your fertility specialist can discuss the likelihood of this resulting in a pregnancy in your situation.  

Advantages:  The highest success rates per month, leading to the shortest time until pregnancy.  If more than one good quality embryo is formed this can be frozen to use if the first treatment doesn't work, or even to create a sibling years after it is frozen.  

Disadvantages:  Risks of ovarian hyperstimulation syndrome, where too many eggs develop and this can make you quite unwell.  Rare risks associated with egg collection.  

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