Açıklanamayan İnfertilite Tanısı Nasıl Konulur?
Özet
Açıklanamayan infertilite, 35 yaş altı çiftlerde 12 ay, 35 yaş üstünde ise 6 ay boyunca düzenli ilişkiye rağmen gebelik oluşmaması ve temel tetkiklerde (ovülasyon, tubal açıklık, uterin kavite, oosit rezervi ve semen analizi) hiçbir sorun bulunamaması durumunda konulan bir dışlama tanısıdır. İnfertil başvuranların yaklaşık %30'unu oluşturan bu grupta, rutin testlerin hassasiyet sınırları veya standart olarak bakılmayan mikroskobik/fonksiyonel faktörler nedeniyle kesin neden saptanamaz. Erkek faktöründe DSÖ referans değerlerine göre semen analizi istenirken, kadınlarda ovülasyon düzeni, serum progesteron, AMH ve ultrasonografi ile over rezervi ve HSG veya laparoskopi ile tüplerin durumu incelenir. Olası gizli nedenler arasında laparoskopide gözden kaçabilen hafif endometriozis, tubal siliyer fonksiyon bozuklukları, implantasyon penceresi ile embriyo arasındaki senkronizasyon problemleri, servikal mukus ve immünolojik sorunlar yer alır. Ayrıca obezite, stres, sigara ve alkol gibi yaşam tarzı faktörleri de etkilidir. Bu çiftlerin her siklus başına %2-4 oranında spontan gebelik şansı devam etmektedir. Rutin süreçte ileri sperm testleri, postkoital testler, laparoskopi ve immünolojik tetkiklerin yapılması ise önerilmemektedir.
Unexplained infertility is a diagnosis of exclusion applied to couples who fail to conceive despite regular intercourse for 12 months if under 35 years of age or for 6 months if over 35, and whose basic diagnostic evaluations (ovulation, tubal patency, uterine cavity, oocyte reserve, and semen analysis) return normal results. Accounting for approximately 30% of infertile couples, this condition represents a limitation of standard tests rather than a true absence of a cause. In standard evaluations, male factor is assessed via semen analysis using WHO reference values, while female factor involves confirming ovulation through menstrual history or mid-luteal progesterone, evaluating ovarian reserve via AMH, FSH, and antral follicle counts, and assessing tubal and uterine patency through HSG, sonohysterography, or laparoscopy. Potential underlying etiologies include mild endometriosis undetected by imaging, subtle tubal ciliary dysfunction, desynchronization between the embryo and the endometrial implantation window, cervical mucus anomalies, and immunological factors. Additionally, lifestyle habits such as obesity, stress, smoking, and alcohol use can negatively impact fertility via endocrine and oxidative mechanisms. Despite the diagnosis, these couples retain a 2-4% chance of spontaneous conception per cycle, and running unrecommended routine tests like advanced sperm function, postkoital, or routine immunologic evaluations is discouraged.
Referanslar
Practice Committee of tAmerican Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss. Fertil Steril. 2008 Nov;90(5 Suppl):S60. doi: 10.1016/j.fertnstert.2008.08.065. PMID: 19007647.
Fernando Zegers-Hochschild, G David Adamson, Silke Dyer, Catherine Racowsky, Jacques de Mouzon, Rebecca Sokol, Laura Rienzi, Arne Sunde, Lone Schmidt, Ian D Cooke, Joe Leigh Simpson, Sheryl van der Poel, The International Glossary on Infertility and Fertility Care, 2017, Human Reproduction, Volume 32, Issue 9, September 2017, Pages 1786–1801, https://doi.org/10.1093/humrep/dex234
P.G. Crosignani, J. Collins, I.D. Cooke, E. Diczfalusy, B. Rubin, The recommendations of the ESHRE workshop on ‘Unexplained Infertility’, held in Anacapri, August 28–29, 1992, are given below. P.G.Crosignani, J.Collins, I.D.Cooke, E.Diczfalusy and B.Rubin prepared the guidelines on behalf of the group., Unexplained infertility, Human Reproduction, Volume 8, Issue 6, June 1993, Pages 977–980, https://doi.org/10.1093/oxfordjournals.humrep.a138177
Leushuis E, van der Steeg JW, Steures P, et al. Reproducibility and reliability of repeated semen analyses in male partners of subfertile couples. Fertil Steril 2010;94(07):2631–2635
Opsahl MS, et al. Single vs. multiple semen specimens in screening for male infertility factors. A comparison. J Reprod Med. 1996;41:313Y315.
Prior JC, NaessM, Langhammer A, Forsmo S. Ovulation prevalence in women with spontaneous normal-length menstrual cycles–a population-based cohort from HUNT3, Norway. PLoS One 2015; 10(08):e0134473
WHO Scientific Group (1975) The epidemiology of infertility. Technical Report Series No. 582.
National Institute for Health Care Excellence Fertility Problems: Assessment and Treatment NICE Clinical Guidelines [CG156]. United Kingdom: NICE; 2017
Ebner T, Moser M, Shebl O, Sommergruber M, Yaman C, Tews G. Blood clots in the cumulus oocyte complex predict poor oocyte quality and post-fertilization development. Reprod Biomed Online 2008;16(06):801–807
Committee Opinion No. 618, Obstetrics & Gynecology: January 2015 - Volume 125 - Issue 1 - p 268-273 doi: 10.1097/01.AOG.0000459864.68372.ec
Maheux-Lacroix S, Boutin A, Moore L, et al. Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis. Hum Reprod 2014;29(05): 953–963
National Institute for Health Care Excellence Fertility Problems: Assessment and Treatment NICE Clinical Guidelines [CG156]. United Kingdom: NICE; 2017
Tur-Kaspa I, Gal M, Hartman M, Hartman J, Hartman A. A prospective evaluation of uterine abnormalities by saline infusion sonohysterography in 1,009 women with infertility or abnormal uterine bleeding. Fertil Steril 2006;86(06):1731–1735
Ant n AG, Velasco JAG. Role of endometrial receptivity in unexplained infertility. In: Unexplained Infertility. Springer; 2015:185–191
Galliano D, Pellicer A. Potential etiologies of unexplained infertility in females. In: Unexplained Infertility. Springer; 2015:141–147
Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril 2012;98(03):591–598
Smith S, Pfeifer SM, Collins JA. Diagnosis and management of female infertility. JAMA 2003;290(13):1767–1770
Polyzos NP, et al. Treatment of unexplained infertility with aromatase inhibitors or clomiphene citrate: a systematic review and meta-analysis. Obstet Gynecol Surv. 2008;63:472Y479.
Infertility Workup for the Women’s Health Specialist, Obstetrics & Gynecology: June 2019 - Volume 133 - Issue 6 - p e377-e384 doi: 10.1097/AOG.0000000000003271
