Dear Lord Winston,
I suffer from migraines and in the past year, I have noticed that they evolved into hormonal / menstrual migraines. Typically, I get a migraine on the following: – between 7-10 days before my period – 2-3 days before my period – on day 1 or 2 of my period (this can be severe) – then on day 5/7 when I feel my hormones change again I have been TTC my first child for 2 years now and have been diagnosed with unexplained infertility. I have had a fair number of tests: laparoscopy (found x2 spots of endometriosis), and my hormonal tests – FSH, LH & progesterone came back all normal. Thyroid function is fine too. My husband has had a sperm analysis which is normal. I have a normal BMI & exercise x2 a week with my husband. We have been told that we will need to start fertility treatment in 2015 but I am very worried that my hormonal imbalance could be a root cause of our infertility? I would very much appreciate your advice on whether my migraines could be linked? I really feel that there could be a link! I currently see a neurologist and have been prescribed naproxen / almotriptans to help. I look forward to your reply, Thank you, K.

Reply…

Dear K,

I am afraid I am no expert on migraine and I know of no clear relationship with infertility, beyond stress.
There is too little here to make any really useful suggestions I am afraid. Was the HSG normal? Are you ovulating? What did the ultrasound show?
If you do have genuine unexplained infertility, the results of long-standing research and recent reviews do not show any advantage in having more treatment such as IVF or IUI. For your information and for the benefit of the website, I enclose my short essay on the subject.

Some thoughts about the treatment of Unexplained Infertility

This may be unpopular with many of my colleagues, as it may disturb many patients who opt for IVF or intrauterine insemination. In recent years a great deal of research has gone into the medical management of unexplained infertility and it is clear, from various studies, that in many centres around the world, there is much over treatment. Many of the regular methods of helping people with unexplained infertility are quite unnecessary.

Over 20 years ago, two colleagues Patrick Taylor and John Collins wrote a detailed account of the subject in their book ‘Unexplained Infertility’, now sadly out of print[1]. In over 250 pages, they wrote what I consider the best account of unexplained infertility ever written. Whilst showing great sensitivity towards couples with this ‘diagnosis’, they gave a detailed mathematical analysis. They evaluated the likelihood of getting pregnant when, after careful diagnosis, this condition was treated by various means including IVF. What they showed was that most of the treatments that had been used had not been properly compared with no treatment at all. In essence what their book reports is that virtually all treatments that are used are no better than doing nothing. I quote the last paragraph of their penultimate chapter:

“….on the issue of efficacy, however, only clomiphene therapy has been demonstrated by means of acceptable clinical evidence in the form of randomized trials as a treatment with proven superiority of no therapy. On the basis of best available evidence, HMG (gonadotrophins) plus intrauterine insemination has possible but unproven benefit, and no studies exist to demonstrate a benefit for in vitro fertilization methodology”.

Over twenty years later, this statement seems to be still justified. Dr Fleur Kersten from Nijmegen in Holland and her colleagues have just published an important study on this subject this month[2]. They collected records from 25 clinics and identified 544 infertile couples who had been carefully examined and who had no clearly identifiable cause for their infertility. The average length they had been infertile was 1.5 years. The patients they define as having unexplained infertility included a number who only had one tube clearly open, some had mild male infertility (motile sperm count ranging from 3 – 10 million) and some mild endometriosis. Any female patient over 38 was excluded.

Of these 544 couples, 198 had had what Dr Kersten called overtreatment – that is, within six months of presenting with infertility they had had ovarian stimulation or IVF. 346 couples had no treatment but were simply followed expectantly for one year. In the treated group, 28% got pregnant within six months of starting the survey and in the untreated group 31% had a pregnancy. After one year, 42% in the treated group got pregnant and in the untreated group 41%. Eventually, 90% of the treated group had a pregnancy compared with 91% in the untreated group who had a pregnancy naturally.

Firstly the authors point out that treatment often seemed to delay the much wanted successful outcome. Secondly, some mild causes of infertility – for example, an apparently rather low sperm count do not necessarily condemn anxious couples to a life of sterility. Thirdly, it is very clear that after thorough testing and a diagnosis of genuinely unexplained infertility carefully diagnosed, there is an excellent chance of having a pregnancy naturally without expensive treatment. Perhaps the message should be – ‘just think of the number of women who have got pregnant spontaneously after several IVF cycles have failed’.

References:

[1] Unexplained Infertility by Patrick J Taylor & John A Collins, Oxford University Press, New York and Oxford, 1992.

[2] F.A.M. Kersten et al. Overtreatment in couples with unexplained infertility. Human Reproduction 2015 Jan;30(1):71-80

Professor Robert Winston

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