New guidelines for treating unexplained infertility

New evidence-based guidelines hope to enable health professionals to better inform people affected by unexplained infertility and increase the chances of pregnancy.

Up to 30% of infertile heterosexual couples are affected by ‘unexplained’ infertility, which cannot be assigned a direct cause.

The diagnosis is made when no abnormalities of the female or male reproductive systems are clearly identified, mostly by excluding possible causes such as the absence of ovulation or low sperm count.

The Centre for Research Excellence in Women’s Health in Reproductive Life (CRE WHiRL), which is administered by Monash University, partnered with the European Society of Human Reproduction and Embryology (ESHRE) in developing the international guidelines, then engaged Australian experts and consumers to adapt these for use in Australia.

New evidence-based recommendations

Led by experts at the University of Adelaide, UNSW Sydney and Monash University, the Australian guideline has been published in the Medical Journal of Australia alongside the launch of consumer resources including a new Monash Ask Fertility App.

The Australian Evidence-based Guideline for Unexplained Infertility: Adapted from the ESHRE Evidence-based Guideline for Unexplained Infertility was developed in response to a priority from the state and federal governments with growing concern about evidence-based practice in the fertility industry, and an increasing cost to government and consumers.

The adapted guideline is approved by NHMRC and endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the Fertility Society of Australia and New Zealand (FSANZ).

It advances understanding of infertility prognosis and treatment and has new evidence-based recommendations so that women and their partners can make informed decisions and avoid expensive, ineffective or unproven treatments.

Consumers, including Indigenous and women from culturally and linguistically diverse (CALD) backgrounds, have been engaged in guideline development and translation.
CRE WHiRL is led by Monash University’s Professor Helena Teede, who joined the University of Adelaide’s Professor Robert Norman and UNSW Sydney’s Dr Michael Costello as the experts leading the guideline.

Teede said the guideline was developed using the most robust processes, involved all stakeholders including those with lived experience of infertility, and was approved by the NHMRC, so the community could be reassured it was trustworthy.

“Unexplained infertility greatly impacts quality of life, and it is important to ensure those affected receive the best advice and care for optimal outcomes, whilst avoiding rapidly rising use of often unproven treatments, increasing costs and inequity seen in Australia for those with unexplained infertility,” Teede said.

Streamline, simplify treatments

“This new guideline will help to streamline and simplify treatments, potentially reducing cost and increasing equity, by avoiding complex testing and treatments that were not necessarily evidence-based. The guideline’s evidence-based advice will play an important role in improving health outcomes for those with unexplained infertility and is adapted for the Australian health system and context,” Norman said.

Infertility is defined as the inability to achieve pregnancy after 12 months of regular unprotected intercourse and affects around 15% of couples. It is increasing due to ecosocial factors including advancing maternal age and rising weight, both of which adversely affect fertility.

“This year, IVF is estimated to cost the government $500 million through Medicare, with another $200 million at a cost for consumers in out-of-pocket expenses. If fully implemented, this guideline could potentially save more than $100 million in unnecessary health procedure costs annually, while maintaining current pregnancy chances and widening access to treatment,” Norman said.

Costello said that, until now, this had been compounded by a lack of evidence-based guidelines and limited independent consumer information and empowerment strategies.

“The ESHRE and Australian guideline uses the best available scientific evidence to guide health professionals in diagnosing and treating those with unexplained infertility,” he said.

Effective management of the condition

The guideline outlines the definition of unexplained infertility, diagnostic tests, treatments and differences between explained and unexplained infertility.

It is aimed at but not limited to general practitioners, gynaecologists, andrologists, infertility specialists, reproductive surgeons and those with unexplained infertility.

“The guideline aims to assist healthcare professionals and couples in appropriate and effective management of the condition, acknowledging that each medical decision must consider individual characteristics, preferences, socioeconomic status, beliefs and values,” Costello said.

“It should also be acknowledged that couples with unexplained infertility may experience considerable impact on their quality of life and they can be offered support and therapeutic counselling.”

Norman and Costello are presenting an outline of the guideline, for the first time, to FSANZ on Tuesday, 17 September in Perth.

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