Process of Assisted Reproductive Technologies (9% per cycle) than either superovulation (4%) or IUI (5%) alone (302). Laparoscopy to treat minimal or mild endometriosis is associated with live birth rates similar to those in patients with unexplained infertility who receive COH/IUI (70% over four cycles) (311). In women over the age of 40, non-ART therapies are much less effective and IVF should be offered as an initial or early treatment option (312). Pregnancy rates per cycle for unexplained infertility in women who are less than 40 years old have been grouped by treatment modality and reported as follows: (i) clomiphene/IUI 7.8%, (ii) gonadotropin/IUI 9.8%, and (iii) IVF 30.7% (313). The use of ICSI or splitting sibling oocytes between IVF and ICSI has been proposed as an approach to unexplained infertility patients to diagnose and treat underlying occult male or oocyte factors (293,314). Although ICSI does improve fertilization rates and reduce fertilization failure, no differences have been noted in pregnancy or live birth rates when comparing IVF to ICSI for unexplained infertility (314,315).
Cost-Effectiveness According to computerized decision-tree modeling, laparoscopy followed by expected management for unexplained infertility may be cost-effective when compared to no intervention, non-ART treatment, or IVF (294). Given that 15 gonadotropin/IUI cycles are needed to produce one additional pregnancy when compared to intracervical insemination alone, IVF seems a reasonable option (150). In Massachusetts, where insurance companies are required to cover infertility treatment, the cost-effectiveness of IVF in the treatment of unexplained infertility was determined. Couples were randomized to accelerated treatment with three cycles of clomiphene citrate/IUI followed by up to six cycles of IVF if no pregnancy occurred (n = 256) versus conventional treatment with clomiphene/IUI for three cycles, then injectable gonadotropins/IUI for three cycles, then IVF for six cycles (n = 247). Median time to pregnancy was 8 months in the accelerated versus 11 months in the conventional treatment groups. The authors used an average cost per cycle with clomiphene/IUI of $500, with gonadotropin/IUI of $2,500, and assuming IVF costs were less than $17,749 per cycle. They reported that the accelerated treatment protocol resulted in a savings of $2,624 per couple and lowered the per delivery charges by $9,856 compared to conventional treatment regimens. The study concluded that couples with unexplained infertility who have not achieved pregnancy after three cycles of clomiphene/IUI should proceed directly to IVF (313).
ART include IVF, ICSI, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), cryopreserved embryo transfers, and the use of donor oocytes. Because of improved success rates associated with IVF-embryo transfer, the performance of GIFT and ZIFT has declined in the United States, so this review will focus primarily on IVF and ICSI (316). Both processes involve:
Prevention of a premature LH surge
Transfer of fresh embryos
Cryopreservation of surplus embryos
Prevention of Premature Luteinizing Hormone Surge