American Society for Reproductive Medicine

Evidence-based Treatments for Couples with Unexplained Infertility

2020United States

Ce document comprend 11 recommandations, 96 références et 4 tableaux.

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Lire la recommandation officielleInterroger Osler sur cette recommandation

Synthèse

Up to 30% of couples experiencing infertility are diagnosed with unexplained infertility after a standard evaluation. Since no treatable cause is identified, treatment is by necessity empiric. Commonly used treatments include ovarian stimulation with oral medications or injectable gonadotropins with intrauterine insemination, and in vitro fertilization.

Messages clés

For most couples with unexplained infertility, the best initial therapy is a course (typically 3 or 4 cycles) of OS and IUI, either with clomiphene or letrozole, followed by IVF for those couples unsuccessful in achieving a pregnancy with OS and IUI.
There is a pressing need for additional therapies to bridge the wide gap in effectiveness between OS and IUI with oral medications and IVF.
Further research is needed into methods to improve access to care, including ART treatments.

Recommandations

INTRAUTERINE INSEMINATION (IUI), NATURAL CYCLE

It is not recommended to perform IUI in natural cycles for the treatment of unexplained infertility. It is less effective than OS with IUI and likely no more effective than expectant management.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
StrongNiveau de preuve : grade aTreatment

CLOMIPHENE CITRATE WITH INTERCOURSE

It is not recommended to use clomiphene citrate with timed intercourse as a treatment for unexplained infertility, as it is no more effective than expectant management.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
ModerateNiveau de preuve : grade bTreatment

AROMATASE INHIBITORS WITH INTERCOURSE

It is not recommended to use letrozole with timed intercourse as a treatment for unexplained infertility, as it is no more effective than expectant management.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
ModerateNiveau de preuve : grade bTreatment

GONADOTROPINS WITH INTERCOURSE

It is not recommended to use gonadotropins with timed intercourse in the treatment of unexplained infertility. Studies report either no difference in pregnancy outcomes compared to OS with oral agents or higher pregnancy rates associated with a higher risk of multiple-gestation pregnancy.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
ModerateNiveau de preuve : grade bTreatment

CLOMIPHENE CITRATE WITH INTRAUTERINE INSEMINATION (IUI)

It is recommended to use clomiphene citrate with IUI in the treatment of couples with unexplained infertility.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
StrongNiveau de preuve : grade aTreatment

AROMATASE INHIBITORS WITH INTRAUTERINE INSEMINATION (IUI)

It is recommended that letrozole with IUI treatments be considered as an alternative regimen for couples with unexplained infertility, as studies to date suggest similar efficacy. Of note, letrozole is not FDA approved for treatment of unexplained infertility, but is considered an effective and well tolerated option.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
StrongNiveau de preuve : grade aTreatment

INTRAUTERINE INSEMINATION (IUI) WITH COMBINATION OF CLOMIPHENE CITRATE OR LETROZOLE AND GONADOTROPINS (LOW DOSE AND CONVENTIONAL DOSE)

It is not recommended to use letrozole or clomiphene citrate plus conventional-dose gonadotropins with IUI, as most studies associated with improved pregnancy rate over OS-IUI with oral medications are also associated with an increased risk of multiple-gestation pregnancy.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
ModerateNiveau de preuve : grade bTreatment

INTRAUTERINE INSEMINATION (IUI) WITH LOW-DOSE GONADOTROPINS

It is not recommended to use low-dose gonadotropins with IUI in the treatment of unexplained infertility, as it is more complex and expensive, and likely no more effective than OS with oral medications with IUI.
Patients concernés: Couples with unexplained infertilitySituation: Unexplained infertility
ModerateNiveau de preuve : grade bTreatment

Évaluation du niveau de preuve

Système de gradation

ASRM Quality of Evidence and Strength of Recommendations

Niveaux de preuve

Grade A: High confidence in evidence. Larger or further study very unlikely to change reported effect.
Grade B: Moderate confidence in evidence. Larger or further studies not likely to change reported effect but may more precisely identify magnitude of effect.
Grade C: Low confidence in evidence. Evidence lacking to support reported effect.
Quality Low: Insufficient sample size; discrepancies among reported data; errors in study design or analysis; missing significant information; unclear or inconsistent results; high risk of bias; high uncertainty about validity of conclusions.
Quality High: Target population clearly identified; sufficient sample size for the study design; clear description of study design; appropriate control(s); generalizable results; definitive conclusions; minimal risk of bias; limitations do not invalidate conclusions. Evidence primarily based on well-designed systematic reviews or meta-analyses of randomized controlled trials.
Quality Intermediate: Target population; sufficient sample size but could benefit from larger studies; control group identified; reasonably consistent results which limitations do not invalidate; fairly definitive conclusions; low risk of bias. Evidence primarily based on small RCTs, systematic reviews/meta-analyses of combination of RCTs and observational studies, and/or well-designed observational studies.

Grade des recommandations

Strong: Strong degree of confidence that stated recommendation reflects best practice approach. Recommendation based on consistent evidence of high quality, consideration that benefit outweighs potential risks, and consensus of expert task force and Practice Committee review.
Moderate: Moderate degree of confidence that stated recommendation reflects best practice approach. Recommendation based on limited evidence of high quality or mix of evidence of high and intermediate quality or consistent body of evidence mostly of intermediate quality, consideration that benefit outweighs potential risks, and consensus.
Weak/Conditional: Low degree of confidence in stated recommendation. Low quality or insufficient evidence to assess true measure of effect. Limited ability to assess benefit vs. risk of intervention.
No recommendation: Insufficient available evidence, lack of confidence or consensus to provide a recommendation for clinical practice.

Échelle de gradation

components: Quality of Evidence (High, Intermediate, Low); Strength of Evidence (Grade A, Grade B, Grade C); Strength of Recommendation (Strong, Moderate, Weak/Conditional, No recommendation)
System name: ASRM Quality of Evidence and Strength of Recommendations

Evidence-based Treatments for Couples with Unexplained Infertility

Synthèse

Messages clés

Recommandations

INTRAUTERINE INSEMINATION (IUI), NATURAL CYCLE

CLOMIPHENE CITRATE WITH INTERCOURSE

AROMATASE INHIBITORS WITH INTERCOURSE

GONADOTROPINS WITH INTERCOURSE

CLOMIPHENE CITRATE WITH INTRAUTERINE INSEMINATION (IUI)

AROMATASE INHIBITORS WITH INTRAUTERINE INSEMINATION (IUI)

INTRAUTERINE INSEMINATION (IUI) WITH COMBINATION OF CLOMIPHENE CITRATE OR LETROZOLE AND GONADOTROPINS (LOW DOSE AND CONVENTIONAL DOSE)

INTRAUTERINE INSEMINATION (IUI) WITH LOW-DOSE GONADOTROPINS

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