10. Act on prognosis for live birth: The diagnostic pathway should provide the couple and healthcare worker with information of the underlying cause(s) of infertility and the prognosis for live birth with and without infertility treatment, including the chance of pregnancy and length of time to achieve pregnancy with different treatment options (Adamson, 2010). Further decisions and actions should be based on the prognosis, which should be revised regularly based on response to treatment and other changes in prognostic factors.
The purpose of infertility investigations is to identify the optimal management pathway for each couple. Any decisions regarding treatment need to acknowledge the fact that a clinical diagnosis of infertility signifies lack of pregnancy over the preceding 12 months or more, rather than absolute sterility. While conditions such as anovulation, tubal disease and severe male factor infertility warrant early active intervention, many couples with unexplained infertility, where no obvious barrier to pregnancy can be identified, are likely to get pregnant on their own. (Evers, 2002; Guzick, 1994; Gurunath, 2011) The decision to initiate treatment, therefore, depends on how a couple’s chances of spontaneous pregnancy compare with those associated with active treatment. Follow-up studies have reported treatment-independent pregnancy rates of up to 50% in unexplained and mild male factor infertility while data from randomized trials suggest that “good prognosis” couples can expect live birth rates comparable with those following active treatment, but without the attendant risks. A number of prognostic models have been used successfully in certain parts of the world to predict reproductive outcomes in couples presenting with infertility. Validation exercises suggest that these can be used to estimate reliably the chance of spontaneous pregnancy and, hence, can be used to counsel couples contemplating fertility treatment. (Hunault, 2005; van der Steeg, 2007)
Thus, the diagnostic pathway should discriminate between couples who need early access to treatment and those who should be encouraged to try for a spontaneous pregnancy.
Active intervention should be offered to couples in whom the chances of getting pregnant on their own are poor, but who have a good chance of getting pregnant with the help of appropriate therapy. This message is particularly relevant in low-resource settings where the cost of treatment is relatively very high and potentially catastrophic. (Xu et al, 2003)