A 28-year-old woman from Delhi presents to the infertility clinic with her husband. They have been trying to conceive for 2 years without success. She has regular menstrual cycles of 28 days. Her BMI is 22 kg/m², and general examination is unremarkable. Pelvic ultrasound shows normal uterus and tubes, and no evidence of PCOS. Her husband's semen analysis is normal. Serum FSH on day 3 is 6 mIU/mL, LH is 5 mIU/mL, and prolactin is 15 ng/mL. Hysterosalpingography is normal. What is the most appropriate next step in management?

Explanation

## Clinical Context This is a case of **unexplained infertility** — a couple with 2 years of infertility, normal semen analysis, normal ovulatory cycles, patent tubes on HSG, and normal baseline hormonal parameters. ## Management Algorithm for Unexplained Infertility ```mermaid flowchart TD A[Unexplained Infertility<br/>Normal investigations]:::outcome --> B{Duration & Age?}:::decision B -->|< 3 years, age < 35| C[Expectant management<br/>+ Timed intercourse]:::action B -->|> 3 years OR age > 35| D[Consider IUI or IVF]:::action C --> E[Reassess at 6-12 months]:::action D --> F[Baseline counselling<br/>Success rates]:::action ``` ## Why Expectant Management? **Key Point:** In unexplained infertility with duration < 3 years and woman's age < 35, **expectant management with timed intercourse is the first-line approach** [cite:ASRM Unexplained Infertility Guidelines]. - Cumulative pregnancy rates at 1 year are 25–30% with expectant management alone - Ovulation induction (clomiphene or gonadotropins) is NOT indicated when ovulation is already normal and regular - Diagnostic laparoscopy is invasive and not recommended as first-line in this scenario **High-Yield:** The key discriminator is **normal ovulatory cycles** — there is no anovulation to treat. Clomiphene and gonadotropins are for anovulation or poor ovulation, not for unexplained infertility with proven ovulation. **Clinical Pearl:** Timed intercourse should occur 2 days before and 1 day after ovulation (predicted by cycle regularity or LH surge detection). ## When to Escalate? If pregnancy does not occur after 6–12 months of expectant management, or if the woman is > 35 years old, then consider: - Intrauterine insemination (IUI) with or without mild ovarian stimulation - In vitro fertilization (IVF)