Still, Rosenwaks does agree that “these days many couples are categorized as unexplained not having had a complete workup. Maybe they have not had a laparoscopy [a microsurgical procedure that allows doctors to look into the pelvis in order to check for and sometimes repair damage from conditions like endometriosis] or they have gone into IVF very quickly because their age justifies it.”
In Richard Paulson’s opinion, skipping such tests can be a good thing. He and many other IVF specialists believe that the standard course of IUI with Clomid and, if that fails, IVF, remains the right approach for women over 35 who receive diagnoses of unexplained infertility. While the premise set forth in Gleicher’s paper—that it’s essential to have a specific diagnosis before beginning treatment—might sound logical, Paulson insists that it doesn’t hold up in the real world. In fact, he believes too much testing can be a waste of time and money. “Twenty years ago, we used to subdivide unexplained infertility into at least 10 other subcategories: cervical mucus problems, subtle ovulatory problems and so on,” he says. “But it turned out that none of those subcategories made any difference in terms of the best way to treat the patient. I could spend thousands of dollars doing additional tests to give them a more specific label than unexplained infertility, but in the end we would start them all on the same treatment: IUI with Clomid, which has been repeatedly shown to increase pregnancy rates in the unexplained infertility population from 3 percent a month to 10 percent a month.”
According to Paulson, the low-tech fixes like cough medicine or antibiotics that David and Fisch recommend fritter away months—months that women over 35 shouldn’t be cavalier about wasting. And skipping Clomid and inseminations, as Gleicher recommends in many cases, deprives couples of a lower-cost treatment (about $500 per month for IUI versus about $10,000 for IVF, in Paulson’s estimates) that has been shown to significantly improve pregnancy rates.
What’s important to keep in mind, says Rosenwaks, is that every case is different. “In medicine, generalization holds only so much, so I don’t think you ought to exclude anything necessarily,” he says. “A patient’s history should dictate how much and what kind of testing should be done.” In the end, as anyone who has struggled to conceive knows, there are many paths to parenthood.