Doing nothing is a treatment option, and it has published numbers
Across couples with unexplained infertility, no treatment beat waiting by a clear margin.
Twenty-seven randomized trials covering 4,349 couples with unexplained infertility were pooled in a network analysis. The comparison everybody wants is treatment against waiting. Here it is, in the reviewers' own absolute framing:
This suggests that if the chance of live birth following expectant management is assumed to be 17%, the chance following OS, IUI, OS-IUI, and IVF would be 9% to 28%, 11% to 33%, 15% to 37%, and 14% to 47%, respectively.
OS is ovarian stimulation with tablets. IUI is intrauterine insemination. OS-IUI is both together.
| Compared with waiting | Odds ratio (95% CI) | Certainty |
|---|---|---|
| Ovarian stimulation | 1.01 (0.51 to 1.98) | Low |
| Insemination alone | 1.21 (0.61 to 2.43) | Low |
| Stimulation plus insemination | 1.61 (0.88 to 2.94) | Low |
| IVF | 1.88 (0.81 to 4.38) | Low |
Every one of those ranges includes the possibility of doing worse than nothing.
A pragmatic Scottish trial randomized 580 women with unexplained infertility of at least two years to clomifene, unstimulated insemination, or expectant management for six months. Live births: 32 of 193 (17%) with expectant management, 26 of 192 (14%) with clomifene, 43 of 191 (23%) with insemination. The authors concluded that these treatments are unlikely to offer superior live birth rates compared with expectant management.
That is not irrational and it is not a criticism of patients. Waiting while your life passes is a real cost, and it is not measured in any of these trials. But it should be your trade-off to make with the numbers in front of you, not a decision made for you by leaving the option unmentioned.
One more figure worth carrying. In the long-term follow-up of an American unexplained infertility trial, among couples who kept trying without treatment after the trial ended, 101 of 157 (64.3%) had a live birth.