Treatment strategies for subfertile couples: Reply

C. Gnoth

Department of Reproductive Medicine and Gynaecological Endocrinology, Staeditische Kliniken Duesseldorf gGmbH, Frauenklinik Benrath, Germany

Dear Sir,

We appreciate the letter of van der Steeg and wish to make our view clear once again (Gnoth et al., 2003Go).

    First, we are not reporting on time to pregnancy in months but in cycles with intercourse in the fertile window which makes an important difference. We have tests that help to discriminate normal fertile from subfertile couples (Eimers et al., 1994Go; Balasch, 2000Go). Because of the huge overlap of test results, the exposure to pregnancy (cycles with intercourse in the fertile window) helps us to decide who will benefit from treatment in the light of assisted reproductive treatment success rates (Evers et al., 1998Go) or should be advised to wait. Therefore reliable data on time to pregnancy as published by our group in normal cycling women are very important for an appropriate management of infertility. Taking into account the results of the overall conception rates for all couples with ~20% of them not conceiving in six and ~10% not conceiving in 12 cycles, approximately every second couple is probably subfertile after six unsuccessful cycles with timed intercourse. We therefore want to suggest a threshold beyond which clinicians should consider subfertility and exclude major factors of infertility. Thereby, we intend to suggest natural family planning methods as a tool for diagnostic assessment of the infertile couple. Our treatment independent conception rate is ~50% after six cycles, which corresponds to rates after 12 months of unsuccessfully trying to achieve a pregnancy in the literature (Snick et al., 1997Go). Nowhere in our paper do we suggest treating all couples after six unsuccessful cycles! Our results help us to decide whether sufficient exposure to the chance of conception has taken place, when to start further infertility investigation and when to resort to assisted reproduction techniques, especially in cases of unexplained infertility. Those with good prognosis should be advised to wait and not be treated and we therefore do not harm couples with possible complications of assisted reproduction techniques. This represents an appropriate management of infertility in our opinion. Future prospective studies should assess whether early interventions by assisted reproduction treatment in cases with poor prognosis after six cycles at higher costs versus late and retarded intervention in cases with good prognosis (unexplained infertility) at lower costs will result in higher cumulative pregnancy rates for all couples at unchanged costs, avoiding under- and overtreatment.

References

Balasch J (2000) Investigation of the infertile couple: investigation of the infertile couple in the era of assisted reproductive technology: a time for reappraisal. Hum Reprod 15,2251–2257.[Abstract/Free Full Text]

Eimers JM, te Velde ER, Gerritse R, Vogelzang ET, Looman CW and Habbema JD (1994) The prediction of the chance to conceive in subfertile couples. Fertil Steril 61,44–52.[Medline]

Evers JL, de Haas HW, Land JA, Dumoulin JC and Dunselman GA (1998) Treatment-independent pregnancy rate in patients with severe reproductive disorders. Hum Reprod 13,1206–1209.[Abstract]

Gnoth C, Godehardt D, Godehardt E, Frank-Herrmann P. and Freundl G (2003) Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod 18,1959–1966.[Abstract/Free Full Text]

Snick HK, Snick TS, Evers JL and Collins JA (1997) The spontaneous pregnancy prognosis in untreated subfertile couples: the Walcheren primary care study. Hum Reprod 12,1582–1588.[Abstract]





This Article
Extract
Full Text (PDF )
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Request Permissions
Google Scholar
Articles by Gnoth, C.
PubMed
PubMed Citation
Articles by Gnoth, C.