Infertility and spontaneous abortion

National Institute for Clinical Excellence. Fertility: assessment and treatment for people with fertility problems [Internet]. London: RCOG Press; 2004 Feb [cited 2009 March 8]. 216 p. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/fertility-assessment-and-treatment-people-fertility-problems

Recommendations grade A

(Evidence from meta-analysis of randomised controlled trials, or at least one randomised controlled trial)

Investigation of fertility problems and management strategies

• The routine use of post-coital testing of cervical mucus in the investigation of fertility problems is not recommended because it has no predictive value on pregnancy rate.

Medical and surgical management of male factor fertility problems

• Men with idiopathic semen abnormalities should not be offered anti-oestrogens, gonadotrophins, androgens, bromocriptine or kinin-enhancing drugs because they have not been shown to be effective.
• Men should be informed that the significance of antisperm antibodies is unclear and the effectiveness of systemic corticosteroids is uncertain.
• Men with leukocytes in their semen should not be offered antibiotic treatment unless there is an identified infection because there is no evidence that this improves pregnancy rates.
• Men should not be offered surgery for varicoceles as a form of fertility treatment because it does not improve pregnancy rates.

Ovulation induction

• Polycystic ovary syndrome

  • Women with World Health Organization Group II ovulation disorders (hypothalamic pituitary dysfunction) such as polycystic ovary syndrome should be offered treatment with clomifene citrate (or tamoxifen) as the first line of treatment for up to 12 months because it is likely to induce ovulation.
  • Anovulatory women with polycystic ovary syndrome who have not responded to clomifene citrate and who have a body mass index of more than 25 should be offered metformin combined with clomifene citrate because this increases ovulation and pregnancy rates.
  • Women with polycystic ovary syndrome who have not responded to clomifene citrate should be offered laparoscopic ovarian drilling because it is as effective as gonadotrophin treatment and is not associated with an increased risk of multiple pregnancy.
  • Women with World Health Organization Group II ovulation disorders such as polycystic ovary syndrome who do not ovulate with clomifene citrate (or tamoxifen) can be offered treatment with gonadotrophins. Human menopausal gonadotrophin, urinary follicle-stimulating hormone and recombinant follicle-stimulating hormone are equally effective in achieving pregnancy and consideration should be given to minimising cost when prescribing.
  • Women with World Health Organization Group II ovulation disorders such as polycystic ovary syndrome who ovulate with clomifene citrate but have not become pregnant after 6 months of treatment should be offered clomifene citrate-stimulated intra-uterine insemination.
  • The effectiveness of pulsatile gonadotrophin-releasing hormone in women with clomifene citrate-resistant polycystic ovary syndrome is uncertain and is therefore not recommended outside a research context.

• Hyperprolactinaemia

  • Women with ovulatory disorders due to hyperprolactinaemia should be offered treatment with dopamine agonists such as bromocriptine. Consideration should be given to safety for use in pregnancy and minimising cost when prescribing.

• Unexplained infertility

  • Women with unexplained fertility problems should be informed that clomifene citrate treatment increases the chance of pregnancy, but that this needs to be balanced by the possible risks of treatment, especially multiple pregnancy.

Medical and surgical management of endometriosis

• Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile women and should not be offered.
• Women with minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis because this improves the chance of pregnancy.
• Women with ovarian endometriomas should be offered laparoscopic cystectomy because this improves the chance of pregnancy.
• Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and is not recommended.

Intra-uterine insemination

• Couples with mild male factor fertility problems, unexplained fertility problems or minimal to mild endometriosis should be offered up to six cycles of intra-uterine insemination because this increases the chance of pregnancy.
• Where intra-uterine insemination is used to manage male factor fertility problems, ovarian stimulation should not be offered because it is no more clinically effective than unstimulated intra-uterine insemination and it carries a risk of multiple pregnancy.
• Where intra-uterine insemination is undertaken, single rather than double insemination should be offered.

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Edited by Aldo Campana,