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Abstract
Background: Unexplained infertility is a term applied to an infertile couple whose standard investigations are normal and whose infertility duration is over two years. Its reported prevalence ranges widely from 6% to 58% depending on evaluation protocols and interpretation of diagnostic studies. Many theories on possible causes for unexplained infertility include follicular and gamete dysfunctions, altered endometrial function, altered uterine blood flow, immunological factors and other factors as endometriosis and women’s anxiety. The diagnosis of unexplained infertility is possible only after a complete infertility evaluation that include semen analysis, laboratory assessment of normal ovulation and finally evaluation of tubal patency and uterine cavity. Semen analysis is evaluated according to the criteria of the WHO (1999). Based on the criteria for normality of the semen analysis, a sperm concentration > 20 millions/ml, total sperm count > 40 millions/ejaculate, motility (within 60 minutes of ejaculation) > 25% with rapid progression and > 50% with forward progression, vitality ≥ 75% live, morphology ≥ 30% normal forms and white blood cells < one million/ml. Ovulation is usually indicated by the existence of a regular menstrual cycle, serum progesterone concentration greater than 3 ng/ml in the midluteal phase and documentation of the LH surge. Tubal patency can be determined by hystersalpingography, which is useful also in evaluation of uterine cavity, sonohysterosalpingography and laparoscopy. These methods are equally good at detecting tubal occlusion, but laparoscopy may be necessary to exclude factors such as endometriosis and adhesions. In addition to hysterosalpingography, uterine cavity can be evaluated also by transvaginal ultrasound and sonohysterography. Hysteroscopy is considered the gold standard for uterine cavity assessment. Different treatment options in unexplained infertility include: expectant management; intrauterine insemination (IUI), ovulation stimulation with clomiphene citrate or with exogenous gonadotropins; superovulation combined with intrauterine insemination; and assisted reproductive technologies (ART.