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New research raises questions about frontline fertility treatments

August 11th, 2008

Dr Petra

Around 1/4 of couples experiencing infertility are described as having ‘unexplained infertility’. That’s when standard tests such as analysing semen, assessing ovulation and checking reproductive organs reveal no apparent reasons for couples not to conceive.

Infertility is distressing and affects around 1 in 7 couples, but for those where there is no clear reason for the problem it can be particularly difficult to cope with.

Where couples are affected by unexplained infertility the usual care procedure is either interuterine insemination, or for a practitioner to prescribe a woman take the drug Clomifene Citrate (Clomid). Clomifene Citrate is something women can take with little medical supervision and is relatively inexpensive, although there are concerns over a potential increased risk of ovarian cancer linked to the medication.

It has generally been accepted that this course of care is correct, but a new study published in the British Medical Journal questions this assumption. You can access the paper here.

The research is worth reading if you are concerned about your fertility, particularly if you are taking Clomifene Citrate or have been recommended this as a potential treatment plan.

The study led by a team of Scottish researchers used a pragmatic randomised controlled trial where 580 couples were recruited over a four year period. 193 were randomised to ‘expectant management’ (where couples were given general advice on fertility – e.g. the importance of regular intercourse, but no medical interventions were provided), 194 were given Clomifene Citrate, and 193 recieved interuterine insemination.

The results were surprising.Clomifene Citrate or interuterine insemination did not appear to be any more effective in tackling unexplained infertility than expectant management. Meaning those patients who were not given any medical interventions were just as likely to have a baby (or not) than those who underwent medical care.

Perhaps unsurprisingly assessment of participants views on their treatment programmes indicated that women who were in the ‘expectant management’ group were less satisfied with the care being offered. After all if you’re worried about getting pregnant being told to have more sex is something you can do but may leave you feeling you’re not doing enough. Being given the option of a medical intervention may give you more hope that something could work – and make you feel you’re doing more to increase your chances of having a baby.

Current guidelines tell practitioners to intervene when couples present with unexplained infertility, but this research challenges those instructions. It seems that couples who are encouraged to have more sex and are given the correct information and support are just as likely to conceive naturally as those who are given medical treatments. The message for practitioners and patients is it may be better to try natural methods before clinical ones, although this obviously should be considered on a case by case basis.

What this means for the way we manage fertility in the UK is yet to be seen. There are some patient groups who have welcomed the study as they are concerned over the associated risks of ovarian cancer related to Clomifene Citrate. Other infertility groups have been angry about the study, seeing it as advocating cost-cutting in the NHS or denying couples treatment.

Certainly if we’re going to move towards expectant management then couples will need more support than that offered in this current study. They will need to know why expectant management is a good idea, why they do not necessarily need a medical intervention, and what they need to do to increase their chances of having a baby. It may also require additional links with support services since couples managing their own fertility often do need other people to talk to.

We also need to improve the way we give sex advice to couples trying for a baby as it’s all very well to say ‘have more sex’ but the reality of doing this as the months go on and still no baby is stressful, tiring and very often boring. Couples fret whether they can use porn, sex toys or fantasy to liven things up, or whether this is a bad way to conceive. Relationships can break down under the pressure of what may feel like forced intimacy, and rather than enjoying sex couples can feel like they’re just having to perform like animals at a stud farm. Sexual dysfunctions are common and advice on how to introduce pleasure to what can become a very routine activity is absent. It is up to couples who are affected by unexplained infertility to request that healthcare providers step up to the plate and start giving this information routinely.

If you are affected by unexplained infertility and are currently taking Clomifene Citrate please do not abandon your treatment plan simply because you’ve heard about this study in the newspapers. Instead you should talk to your doctor about any concerns you have (show them the paper linked above if it helps). If you are being recommended to have interuterine insemination or Clomifene Citrate and you are now uncertain about this then speak to your consultant about whether this is the right option for you. Although expectant management is suggested to be as effective as clinical measures all cases are different and you should talk to your partner and your doctor about what feels right for you.

If you are worried about infertility you can get help and support from the Infertility Network, NHS Direct, or the public information section of the British Fertility Society’s website.

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