Expectant management best for some infertile couples

In couples with unexplained infertility, treatment with either clomifene citrate or unstimulated intrauterine insemination does not result in superior live birth rates compared with expectant management, according to study findings published online Aug. 7 in BMJ Online First.Siladitya Bhattacharya, MD, of the University of Aberdeen in Aberdeen, UK, and colleagues randomly assigned 580 women to expectant management, oral clomifene citrate, or unstimulated intrauterine insemination for 6 months. The three groups were similar to each other in age, body mass index, duration of infertility, sperm concentration, and motility.The researchers found that the odds ratio for a live birth was 0.79 for women who received clomifene citrate and 1.46 for those who received unstimulated intrauterine insemination when compared to expectant management. But they also found that patient satisfaction was lower for expectant management (80%) compared to clomifene citrate and unstimulated intrauterine insemination (94% and 96%, respectively).?High-quality clinical trials to guide policymakers and health care commissioners and, more importantly, to inform patients of optimum treatment options are desperately needed,? states the author of an accompanying editorial. ?In the meantime, how should couples with unexplained infertility be managed? Appropriate selection of couples for the different pathways is crucial. If a woman is under 36 and the duration of infertility is less than 3 years, 6 to 12 months of expectant management is justified, especially if she has previously been pregnant. Older age, a longer duration of infertility, and lack of pregnancy after expectant management should be regarded as indications for a more proactive treatment plan.?Bhattacharya S, Harrild K, Mollison J, et al. Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial. BMJ. 2008;337:a716 (doi:10.1136/bmj.a716).