Pregnancy rates after timed intercourse or intrauterine insemination after human menopausal gonadotropin stimulation of normal ovulatory cycles: a controlled study

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Intrauterine Insemination After Human Chorionic Gonadotropin Trigger or Luteinizing Hormone Surge: A Meta-analysis

OBJECTIVE

To assess the odds of pregnancy after intrauterine insemination (IUI) timed by ultrasound monitoring and human chorionic gonadotropin (hCG) administration compared with monitoring luteinizing hormone (LH) levels.

DATA SOURCES

We searched PubMed (MEDLINE), EMBASE (Elsevier), Scopus (Elsevier), Web of Science (Clarivate Analytics), ClinicalTrials.gov (National Institutes of Health), and the Cochrane Library (Wiley) from the inception until October 1, 2022. No language limitations were applied.

METHODS OF STUDY SELECTION

After deduplication, 3,607 unique citations were subjected to blinded independent review by three investigators. Thirteen studies (five retrospective cohort, four cross-sectional, two randomized controlled trials, and two randomized crossover studies) that enrolled women undergoing natural cycle, oral medication (clomid or letrozole), or both for IUI were included in the final random-effects model meta-analysis. Methodologic quality of included studies was assessed with the Downs and Black checklist.

TABULATION, INTEGRATION, AND RESULTS

Data extraction was compiled by two authors, including publication information, hCG and LH monitoring guidelines, and pregnancy outcomes. No significant difference in odds of pregnancy between hCG administration and endogenous LH monitoring was observed (odds ratio [OR] 0.92, 95% CI 0.69-1.22, P=.53). Subgroup analysis of the five studies that included natural cycle IUI outcomes also showed no significant difference in odds of pregnancy between the two methods (OR 0.88, 95% CI 0.46-1.69, P=.61). Finally, a subgroup analysis of 10 studies that included women who underwent ovarian stimulation with oral medications (clomid or letrozole) did not demonstrate a difference in odds of pregnancy between ultrasonography with hCG trigger and LH-timed IUI (OR 0.88, 95% CI 0.66-1.16, P=.32). Statistically significant heterogeneity was noted between studies.

CONCLUSION

This meta-analysis showed no difference between pregnancy outcomes between at-home LH monitoring and timed IUI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021230520.

Evidence-based treatments for couples with unexplained infertility: a guideline

OBJECTIVE

To provide evidence-based recommendations to practicing physicians and others regarding the effectiveness and safety of therapies for unexplained infertility.

METHODS

ASRM conducted a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1968 through 2019. The ASRM Practice Committee and a task force of experts used available evidence and informal consensus to develop evidence-based guideline recommendations.

MAIN OUTCOME MEASURE(S)

Outcomes of interest included: live-birth rate, clinical pregnancy rate, implantation rate, fertilization rate, multiple pregnancy rate, dose of treatment, rate of ovarian hyperstimulation, abortion rate, and ectopic pregnancy rate.

RESULT(S)

The literature search identified 88 relevant studies to inform the evidence base for this guideline.

RECOMMENDATION(S)

Evidence-based recommendations were developed for the following treatments for couples with unexplained infertility: natural cycle with intrauterine insemination (IUI); clomiphene citrate with intercourse; aromatase inhibitors with intercourse; gonadotropins with intercourse; clomiphene citrate with IUI; aromatase inhibitors with IUI; combination of clomiphene citrate or letrozole and gonadotropins (low dose and conventional dose) with IUI; low-dose gonadotropins with IUI; conventional-dose gonadotropins with IUI; timing of IUI; and in vitro fertilization and treatment paradigms.

CONCLUSION(S)

The treatment of unexplained infertility is by necessity empiric. For most couples, the best initial therapy is a course (typically 3 or 4 cycles) of ovarian stimulation with oral medications and intrauterine insemination (OS-IUI) followed by in vitro fertilization for those unsuccessful with OS-IUI treatments.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely-used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rates.

OBJECTIVES

To determine whether, for couples with unexplained subfertility, the live birth rate is improved following IUI treatment with or without OH compared to timed intercourse (TI) or expectant management with or without OH, or following IUI treatment with OH compared to IUI in a natural cycle.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 17 October 2019, together with reference checking and contact with study authors for missing or unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing IUI with TI or expectant management, both in stimulated or natural cycles, or IUI in stimulated cycles with IUI in natural cycles in couples with unexplained subfertility.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, quality assessment and data extraction. Primary review outcomes were live birth rate and multiple pregnancy rate.

MAIN RESULTS

We include 15 trials with 2068 women. The evidence was of very low to moderate quality. The main limitation was very serious imprecision. IUI in a natural cycle versus timed intercourse or expectant management in a natural cycle It is uncertain whether treatment with IUI in a natural cycle improves live birth rate compared to treatment with expectant management in a natural cycle (odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT, 334 women; low-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle to be 16%, that of IUI in a natural cycle would be between 15% and 34%. It is uncertain whether treatment with IUI in a natural cycle reduces multiple pregnancy rates compared to control (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT, 334 women; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a stimulated cycle It is uncertain whether treatment with IUI in a stimulated cycle improves live birth rates compared to treatment with TI in a stimulated cycle (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs, 208 women; I² = 72%; low-quality evidence). If we assume the chance of achieving a live birth with TI in a stimulated cycle was 26%, the chance with IUI in a stimulated cycle would be between 23% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle reduces multiple pregnancy rates compared to control (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, 316 women; I² = 0%; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a natural cycle In couples with a low prediction score of natural conception, treatment with IUI combined with clomiphene citrate or letrozole probably results in a higher live birth rate compared to treatment with expectant management in a natural cycle (OR 4.48, 95% CI 2.00 to 10.01; 1 RCT; 201 women; moderate-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle was 9%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle results in a lower multiple pregnancy rate compared to control (OR 3.01, 95% CI 0.47 to 19.28; 2 RCTs, 454 women; I² = 0%; low-quality evidence). IUI in a natural cycle versus timed intercourse or expectant management in a stimulated cycle Treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with expectant management in a stimulated cycle (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, 342 women: moderate-quality evidence). If we assume the chance of a live birth with expectant management in a stimulated cycle was 13%, the chance of a live birth with IUI in a natural cycle would be between 14% and 34%. It is uncertain whether treatment with IUI in a natural cycle results in a lower multiple pregnancy rate compared to control (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT, 342 women; low-quality evidence). IUI in a stimulated cycle versus IUI in a natural cycle Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle (OR 2.07, 95% CI 1.22 to 3.50; 4 RCTs, 396 women; I² = 0%; low-quality evidence). If we assume the chance of a live birth with IUI in a natural cycle was 14%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 36%. It is uncertain whether treatment with IUI in a stimulated cycle results in a higher multiple pregnancy rate compared to control (OR 3.00, 95% CI 0.11 to 78.27; 2 RCTs, 65 women; low-quality evidence).

AUTHORS' CONCLUSIONS

Due to insufficient data, it is uncertain whether treatment with IUI with or without OH compared to timed intercourse or expectant management with or without OH improves cumulative live birth rates with acceptable multiple pregnancy rates in couples with unexplained subfertility. However, treatment with IUI with OH probably results in a higher cumulative live birth rate compared to expectant management without OH in couples with a low prediction score of natural conception. Similarly, treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with timed intercourse with OH. Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle.

Interventions for unexplained infertility: a systematic review and network meta-analysis

BACKGROUND

Clinical management for unexplained infertility includes expectant management as well as active treatments, including ovarian stimulation (OS), intrauterine insemination (IUI), OS-IUI,  and in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI).Existing systematic reviews have conducted head-to-head comparisons of these interventions using pairwise meta-analyses. As this approach allows only the comparison of two interventions at a time and is contingent on the availability of appropriate primary evaluative studies, it is difficult to identify the best intervention in terms of effectiveness and safety. Network meta-analysis compares multiple treatments simultaneously by using both direct and indirect evidence and provides a hierarchy of these treatments, which can potentially better inform clinical decision-making.

OBJECTIVES

To evaluate the effectiveness and safety of different approaches to clinical management (expectant management, OS, IUI, OS-IUI, and IVF/ICSI) in couples with unexplained infertility.

SEARCH METHODS

We performed a systematic review and network meta-analysis of relevant randomised controlled trials (RCTs). We searched electronic databases including the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane Central Register of Studies Online, MEDLINE, Embase, PsycINFO and CINAHL, up to 6 September 2018, as well as reference lists, to identify eligible studies. We also searched trial registers for ongoing trials.

SELECTION CRITERIA

We included RCTs comparing at least two of the following clinical management options in couples with unexplained infertility: expectant management, OS, IUI, OS-IUI, and IVF (or combined with ICSI).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts identified by the search strategy. We obtained the full texts of potentially eligible studies to assess eligibility and extracted data using standardised forms. The primary effectiveness outcome was a composite of cumulative live birth or ongoing pregnancy, and the primary safety outcome was multiple pregnancy. We performed a network meta-analysis within a random-effects multi-variate meta-analysis model. We presented treatment effects by using odds ratios (ORs) and 95% confidence intervals (CIs). For the network meta-analysis, we used Confidence in Network Meta-analysis (CINeMA) to evaluate the overall certainty of evidence.

MAIN RESULTS

We included 27 RCTs (4349 couples) in this systematic review and 24 RCTs (3983 couples) in a subsequent network meta-analysis. Overall, the certainty of evidence was low to moderate: the main limitations were imprecision and/or heterogeneity.Ten RCTs including 2725 couples reported on live birth. Evidence of differences between OS, IUI, OS-IUI, or IVF/ICSI versus expectant management was insufficient (OR 1.01, 95% CI 0.51 to 1.98; low-certainty evidence; OR 1.21, 95% CI 0.61 to 2.43; low-certainty evidence; OR 1.61, 95% CI 0.88 to 2.94; low-certainty evidence; OR 1.88, 95 CI 0.81 to 4.38; low-certainty evidence). 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. When only including couples with poor prognosis of natural conception (3 trials, 725 couples) we found OS-IUI and IVF/ICSI increased live birth rate compared to expectant management (OR 4.48, 95% CI 2.00 to 10.1; moderate-certainty evidence; OR 4.99, 95 CI 2.07 to 12.04; moderate-certainty evidence), while there was insufficient evidence of a difference between IVF/ICSI and OS-IUI (OR 1.11, 95% CI 0.78 to 1.60; low-certainty evidence).Eleven RCTs including 2564 couples reported on multiple pregnancy. Compared to expectant management/IUI, OS (OR 3.07, 95% CI 1.00 to 9.41; low-certainty evidence) and OS-IUI (OR 3.34 95% CI 1.09 to 10.29; moderate-certainty evidence) increased the odds of multiple pregnancy, and there was insufficient evidence of a difference between IVF/ICSI and expectant management/IUI (OR 2.66, 95% CI 0.68 to 10.43; low-certainty evidence). These findings suggest that if the chance of multiple pregnancy following expectant management or IUI is assumed to be 0.6%, the chance following OS, OS-IUI, and IVF/ICSI would be 0.6% to 5.0%, 0.6% to 5.4%, and 0.4% to 5.5%, respectively.Trial results show insufficient evidence of a difference between IVF/ICSI and OS-IUI for moderate/severe ovarian hyperstimulation syndrome (OHSS) (OR 2.50, 95% CI 0.92 to 6.76; 5 studies; 985 women; moderate-certainty evidence). This suggests that if the chance of moderate/severe OHSS following OS-IUI is assumed to be 1.1%, the chance following IVF/ICSI would be between 1.0% and 7.2%.

AUTHORS' CONCLUSIONS

There is insufficient evidence of differences in live birth between expectant management and the other four interventions (OS, IUI, OS-IUI, and IVF/ICSI). Compared to expectant management/IUI, OS may increase the odds of multiple pregnancy, and OS-IUI probably increases the odds of multiple pregnancy. Evidence on differences between IVF/ICSI and expectant management for multiple pregnancy is insufficient, as is evidence of a difference for moderate or severe OHSS between IVF/ICSI and OS-IUI.

Effectiveness of spontaneous ovulation as monitored by urinary luteinising hormone versus induced ovulation by administration of human chorionic gonadotrophin in couples undergoing gonadotrophin-stimulated intrauterine insemination: a randomised controlled trial

OBJECTIVE

To compare effectiveness of spontaneous ovulation monitored by urinary luteinising hormone (LH) versus induced ovulation by administration of human chorionic gonadotrophin (hCG) in couples undergoing gonadotrophin-stimulated intrauterine insemination (IUI).

DESIGN

Randomised controlled trial.

SETTING

University-level infertility unit.

POPULATION

Couples with unexplained infertility, mild endometriosis, mild male factor infertility and polycystic ovarian syndrome.

METHODS

Couples were randomised to an LH group (Group A), in which urinary LH was measured daily to detect spontaneous ovulation, or an hCG group (Group B), in which urinary hCG was administered as a trigger.

MAIN OUTCOME MEASURES

Clinical pregnancy rate. Secondary outcomes - ongoing pregnancy, live birth, multiple pregnancy and miscarriage rates.

RESULTS

A total of 392 couples were randomised with 196 in each arm. The clinical pregnancy rate per woman randomised was 14/196 (7.1%) in the LH arm versus 15/196 (7.6%) in the hCG arm (P = 0.847, which was not statistically significant). Similarly, the ongoing pregnancy rates [13/196 (6.6%) versus 14/196 (7.1%); P = 0.84] and the live birth rates [13/196 (6.6%) versus 14/196 (7.1%); P = 0.84] between the two groups did not show any significant difference. The duration of stimulation and gonadotrophin dosage also did not differ significantly between the two methods.

CONCLUSION

There was no significant difference in clinical pregnancy rates when urinary LH and hCG trigger were compared as methods to time insemination in women undergoing gonadotropin-stimulated IUI.

TWEETABLE ABSTRACT

A randomised controlled study showing similar effectiveness between two different methods of timing IUI.

Assisted reproductive technologies for male subfertility

BACKGROUND

Intra-uterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) are frequently used fertility treatments for couples with male subfertility. The use of these treatments has been subject of discussion. Knowledge on the effectiveness of fertility treatments for male subfertility with different grades of severity is limited. Possibly, couples are exposed to unnecessary or ineffective treatments on a large scale.

OBJECTIVES

To evaluate the effectiveness and safety of different fertility treatments (expectant management, timed intercourse (TI), IUI, IVF and ICSI) for couples whose subfertility appears to be due to abnormal sperm parameters.

SEARCH METHODS

We searched for all publications that described randomised controlled trials (RCTs) of the treatment for male subfertility. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO and the National Research Register from inception to 14 April 2015, and web-based trial registers from January 1985 to April 2015. We applied no language restrictions. We checked all references in the identified trials and background papers and contacted authors to identify relevant published and unpublished data.

SELECTION CRITERIA

We included RCTs comparing different treatment options for male subfertility. These were expectant management, TI (with or without ovarian hyperstimulation (OH)), IUI (with or without OH), IVF and ICSI. We included only couples with abnormal sperm parameters.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, extracted data and assessed risk of bias. They resolved disagreements by discussion with the rest of the review authors. We performed statistical analyses in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration. The quality of the evidence was rated using the GRADE methods. Primary outcomes were live birth and ovarian hyperstimulation syndrome (OHSS) per couple randomised.

MAIN RESULTS

The review included 10 RCTs (757 couples). The quality of the evidence was low or very low for all comparisons. The main limitations in the evidence were failure to describe study methods, serious imprecision and inconsistency. IUI versus TI (five RCTs)Two RCTs compared IUI with TI in natural cycles. There were no data on live birth or OHSS. We found no evidence of a difference in pregnancy rates (2 RCTs, 62 couples: odds ratio (OR) 4.57, 95% confidence interval (CI) 0.21 to 102, very low quality evidence; there were no events in one of the studies).Three RCTs compared IUI with TI both in cycles with OH. We found no evidence of a difference in live birth rates (1 RCT, 81 couples: OR 0.89, 95% CI 0.30 to 2.59; low quality evidence) or pregnancy rates (3 RCTs, 202 couples: OR 1.51, 95% CI 0.74 to 3.07; I(2) = 11%, very low quality evidence). One RCT reported data on OHSS. None of the 62 women had OHSS.One RCT compared IUI in cycles with OH with TI in natural cycles. We found no evidence of a difference in live birth rates (1 RCT, 44 couples: OR 3.14, 95% CI 0.12 to 81.35; very low quality evidence). Data on OHSS were not available. IUI in cycles with OH versus IUI in natural cycles (five RCTs)We found no evidence of a difference in live birth rates (3 RCTs, 346 couples: OR 1.34, 95% CI 0.77 to 2.33; I(2) = 0%, very low quality evidence) and pregnancy rates (4 RCTs, 399 couples: OR 1.68, 95% CI 1.00 to 2.82; I(2) = 0%, very low quality evidence). There were no data on OHSS. IVF versus IUI in natural cycles or cycles with OH (two RCTs)We found no evidence of a difference in live birth rates between IVF versus IUI in natural cycles (1 RCT, 53 couples: OR 0.77, 95% CI 0.25 to 2.35; low quality evidence) or IVF versus IUI in cycles with OH (2 RCTs, 86 couples: OR 1.03, 95% CI 0.43 to 2.45; I(2) = 0%, very low quality evidence). One RCT reported data on OHSS. None of the women had OHSS.Overall, we found no evidence of a difference between any of the groups in rates of live birth, pregnancy or adverse events (multiple pregnancy, miscarriage). However, most of the evidence was very low quality.There were no studies on IUI in natural cycles versus TI in stimulated cycles, IVF versus TI, ICSI versus TI, ICSI versus IUI (with OH) or ICSI versus IVF.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether there was any difference in safety and effectiveness between different treatments for male subfertility. More research is needed.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive thAppendixan in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rate. This is an update of a Cochrane review (Veltman-Verhulst 2012) originally published in 2006 and updated in 2012.

OBJECTIVES

To determine whether, for couples with unexplained subfertility, IUI improves the live birth rate compared with timed intercourse (TI), or expectant management, both with and without ovarian hyperstimulation (OH).

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (formerly Cochrane Menstrual Disorders and Subfertility Group) Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to Issue 11, 2015), Ovid MEDLINE, Ovid EMBASE, PsycINFO and trial registers, all from inception to December 2015 and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data. The evidence is current to December 2015.

SELECTION CRITERIA

Truly randomised controlled trial (RCT) comparisons of IUI versus TI, in natural or stimulated cycles. Only couples with unexplained subfertility were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, quality assessment and data extraction. We extracted outcomes, and pooled data and, where possible, we carried out subgroup and sensitivity analyses.

MAIN RESULTS

We included 14 trials including 1867 women. IUI versus TI or expectant management both in natural cycleLive birth rate (all cycles)There was no evidence of a difference in cumulative live births between the two groups (Odds Ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT; n = 334; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI was assumed to be 16%, that of IUI would be between 15% and 34%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT; n = 334; moderate quality evidence). IUI versus TI or expectant management both in stimulated cycleLive birth rate (all cycles)There was no evidence of a difference between the two treatment groups (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs; n = 208; I(2) = 72%; moderate quality evidence). The evidence suggested that if the chance of achieving a live birth in TI was assumed to be 26%, the chance of a live birth with IUI would be between 23% and 50%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rates between the two treatment groups (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, n = 316; I(2) = 0%; low quality evidence). IUI in a natural cycle versus IUI in a stimulated cycle Live birth rate (all cycles)An increase in live birth rate was found for women who were treated with IUI in a stimulated cycle compared with those who underwent IUI in natural cycle (OR 0.48, 95% CI 0.29 to 0.82; 4 RCTs, n = 396; I(2) = 0%; moderate quality evidence). The evidence suggested that if the chance of a live birth in IUI in a stimulated cycle was assumed to be 25%, the chance of a live birth in IUI in a natural cycle would be between 9% and 21%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 0.33, 95% CI 0.01 to 8.70; 2 RCTs; n = 65; low quality evidence). IUI in a stimulated cycle versus TI or expectant management in a natural cycleLive birth rate (all cycles)There was no evidence of a difference in live birth rate between the two treatment groups (OR 0.82, 95% CI 0.45 to 1.49; 1 RCT; n = 253; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI or expectant management in a natural cycle was assumed to be 24%, the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 2.00, 95% CI 0.18 to 22.34; 2 RCTs; n = 304; moderate quality evidence). IUI in natural cycle versus TI or expectant management in stimulated cycle Live birth rate (all cycles)There was evidence of an increase in live births for IUI (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, n = 342; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI in a stimulated cycle was assumed to be 13%, the chance of a live birth in IUI in a natural cycle would be between 14% and 34%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the groups (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT; n = 342; moderate quality evidence).The quality of the evidence was assessed using GRADE methods. Quality ranged from low to moderate, the main limitation being imprecision in the findings for both live birth and multiple pregnancy..

AUTHORS' CONCLUSIONS

This systematic review did not find conclusive evidence of a difference in live birth or multiple pregnancy in most of the comparisons for couples with unexplained subfertility treated with intra-uterine insemination (IUI) when compared with timed intercourse (TI), both with and without ovarian hyperstimulation (OH). There were insufficient studies to allow for pooling of data on the important outcome measures for each of the comparisons.

Synchronised approach for intrauterine insemination in subfertile couples

BACKGROUND

In many countries intrauterine insemination (IUI) is the treatment of first choice for a subfertile couple when the infertility work up reveals an ovulatory cycle, at least one open Fallopian tube and sufficient spermatozoa. The final goal of this treatment is to achieve a pregnancy and deliver a healthy (singleton) live birth. The probability of conceiving with IUI depends on various factors including age of the couple, type of subfertility, ovarian stimulation and the timing of insemination. IUI should logically be performed around the moment of ovulation. Since spermatozoa and oocytes have only limited survival time correct timing of the insemination is essential. As it is not known which technique of timing for IUI results in the best treatment outcome, we compared different techniques for timing IUI and different time intervals.

OBJECTIVES

To evaluate the effectiveness of different synchronisation methods in natural and stimulated cycles for IUI in subfertile couples.

SEARCH METHODS

We searched for all publications which described randomised controlled trials of the timing of IUI. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (1966 to October 2014), EMBASE (1974 to October 2014), MEDLINE (1966 to October 2014) and PsycINFO (inception to October 2014) electronic databases and prospective trial registers. Furthermore, we checked the reference lists of all obtained studies and performed a handsearch of conference abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing different timing methods for IUI were included. The following interventions were evaluated: detection of luteinising hormone (LH) in urine or blood, single test; human chorionic gonadotropin (hCG) administration; combination of LH detection and hCG administration; basal body temperature chart; ultrasound detection of ovulation; gonadotropin-releasing hormone (GnRH) agonist administration; or other timing methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted the data and assessed study risk of bias. We performed statistical analyses in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Eighteen RCTs were included in the review, of which 14 were included in the meta-analyses (in total 2279 couples). The evidence was current to October 2013. The quality of the evidence was low or very low for most comparisons . The main limitations in the evidence were failure to describe study methods, serious imprecision and attrition bias.Ten RCTs compared different methods of timing for IUI. We found no evidence of a difference in live birth rates between hCG injection versus LH surge (odds ratio (OR) 1.0, 95% confidence interval (CI) 0.06 to 18, 1 RCT, 24 women, very low quality evidence), urinary hCG versus recombinant hCG (OR 1.17, 95% CI 0.68 to 2.03, 1 RCT, 284 women, low quality evidence) or hCG versus GnRH agonist (OR 1.04, 95% CI 0.42 to 2.6, 3 RCTS, 104 women, I(2) = 0%, low quality evidence).Two RCTs compared the optimum time interval from hCG injection to IUI, comparing different time frames that ranged from 24 hours to 48 hours. Only one of these studies reported live birth rates, and found no difference between the groups (OR 0.52, 95% CI 0.27 to 1.00, 1 RCT, 204 couples). One study compared early versus late hCG administration and one study compared different dosages of hCG, but neither reported the primary outcome of live birth.We found no evidence of a difference between any of the groups in rates of pregnancy or adverse events (multiple pregnancy, miscarriage, ovarian hyperstimulation syndrome (OHSS)). However, most of these data were very low quality.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether there is any difference in safety and effectiveness between different methods of synchronization of ovulation and insemination. More research is needed.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rate.

OBJECTIVES

To determine whether, for couples with unexplained subfertility, IUI improves the live birth rate compared with timed intercourse (TI), both with and without ovarian hyperstimulation (OH).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 7), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), PsycINFO (1806 to July 2011), SCIsearch and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data.

SELECTION CRITERIA

Truly randomised controlled trials (RCTs) with at least one of the following comparisons were included: IUI versus TI, both in a natural cycle; IUI versus TI, both in a stimulated cycle; IUI in a natural cycle versus IUI in a stimulated cycle; IUI with OH versus TI in a natural cycle; IUI in a natural cycle versus TI with OH. Only couples with unexplained subfertility were included.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two review authors. Outcomes were extracted and the data were pooled. Subgroup and sensitivity analyses were done where possible.

MAIN RESULTS

One trial compared IUI in a natural cycle with expectant management and showed no evidence of increased live births (334 women: odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.8). In the six trials where IUI was compared with TI, both in stimulated cycles, there was evidence of an increased chance of pregnancy after IUI (six RCTs, 517 women: OR 1.68, 95% CI 1.13 to 2.50). A significant increase in live birth rate was found for women where IUI with OH was compared with IUI in a natural cycle (four RCTs, 396 women: OR 2.07, 95% CI 1.22 to 3.50). However the trials provided insufficient data to investigate the impact of IUI with or without OH on several important outcomes including live births, multiple pregnancies, miscarriage and risk of ovarian hyperstimulation. There was no evidence of a difference in pregnancy rate for IUI with OH compared with TI in a natural cycle (two RCTs, total 304 women: data not pooled). The final comparison of IUI in natural cycle to TI with OH showed a marginal, significant increase in live births for IUI (one RCT, 342 women: OR 1.95, 95% CI 1.10 to 3.44).

AUTHORS' CONCLUSIONS

There is evidence that IUI with OH increases the live birth rate compared to IUI alone. The likelihood of pregnancy was also increased for treatment with IUI compared to TI in stimulated cycles. One adequately powered multicentre trial showed no evidence of effect of IUI in natural cycles compared with expectant management. There is insufficient data on multiple pregnancies and other adverse events for treatment with OH. Therefore couples should be fully informed about the risks of IUI and OH as well as alternative treatment options.

An algorithm combining ultrasound monitoring and urinary luteinizing hormone testing: a novel approach for intrauterine insemination timing

OBJECTIVE

Intrauterine insemination (IUI) is a commonly used treatment for infertility. Optimal timing of insemination is achieved either by ultrasound monitoring of follicular growth followed by the administration of human chorionic gonadotropin (hCG) or by the detection of a luteinizing hormone (LH) surge through urinary LH testing (uLH). However, in cycles where follicular growth is monitored, there is a possibility of a premature LH rise which may affect the outcome of treatment. The objective of the current study was to determine the frequency of spontaneous LH surges in ultrasound-monitored IUI cycles.

METHODS

One hundred IUI cycles were followed for this prospective cohort study. In combination with ultrasound monitoring, uLH testing was performed twice daily. A serum LH test was performed in the case of an inconclusive uLH test result. IUI was performed either on the day after a positive LH test or, if the diameter of the dominant follicle reached 18 mm and the LH test was still negative, 36 hours after ovulation triggering by administration of hCG.

RESULTS

Of the 87 analyzed cycles, 19 (21.8%) exhibited a premature LH surge as detected by urine testing. Eleven further cycles had an inconclusive urine result, and in six of these (6.9% of cycles) the result was confirmed positive by serum LH testing, giving a total of 25 cycles (28.7%) experiencing a premature LH surge.

CONCLUSION

A considerable proportion of patients undergoing ultrasound-monitored IUI cycle had a spontaneous LH surge before ovulation triggering was scheduled. This could affect pregnancy rates following IUI.

Synchronised approach for intrauterine insemination in subfertile couples

BACKGROUND

Intrauterine insemination (IUI) should logically be performed around the moment of ovulation. Since spermatozoa and oocytes have only limited survival times correct timing is essential. As it is not known which technique of timing for IUI results in the best treatment outcome, we compared different techniques for timing IUI and different time intervals.

OBJECTIVES

To evaluate the effectiveness of different synchronisation methods in natural and stimulated cycles for IUI in subfertile couples.

SEARCH STRATEGY

We searched for all publications which described randomised controlled trials of the timing of IUI. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), (1966 to March 2009), EMBASE (1974 to March 2009) and Science Direct (1966 to March 2009) electronic databases. Furthermore, we checked the reference lists of all obtained studies and performed a handsearch of conference abstracts.

SELECTION CRITERIA

Only truly randomised controlled trials comparing different timing methods for IUI were included. The following interventions were evaluated: detection of luteinising hormone (LH) in urine or blood, single test; human chorionic gonadotropin (hCG) administration; combination of LH detection and hCG administration; basal body temperature chart; ultrasound detection of ovulation; gonadotropin-releasing hormone (GnRH) agonist administration; or other timing methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials to be included according to the above mentioned criteria. We performed statistical analyses in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration.

MAIN RESULTS

Ten studies were included comparing urinary LH surge versus hCG injection; recombinant hCG versus urinary hCG; and hCG versus a GnRH agonist. One study compared the optimum time interval from hCG injection to IUI. The results of these studies showed no significant differences between different timing methods for IUI expressed as live birth rates: hCG versus LH surge (odds ratio (OR) 1.0, 95% CI 0.06 to 18); urinary hCG versus recombinant hCG (OR 1.2, 95% CI 0.68 to 2.0); and hCG versus GnRH agonist (OR 1.1, 95% CI 0.42 to 3.1). All the secondary outcomes analysed showed no significant differences between treatment groups.

AUTHORS' CONCLUSIONS

There is no evidence to advise one particular treatment option over another. The choice should be based on hospital facilities, convenience for the patient, medical staff, costs and drop-out levels. Since different time intervals between hCG and IUI did not result in different pregnancy rates, a more flexible approach might be allowed.

What is the most valid comparison treatment in trials of intrauterine insemination, timed or uninfluenced intercourse? A systematic review and meta-analysis of indirect evidence

BACKGROUND

Timed intercourse (TI), which is the usual control treatment in trials of intrauterine insemination (IUI), is not a typical coital activity and could impair fertility. This review summarizes the trials of IUI of male partner's prepared semen among subfertile couples according to whether the control group had TI or expectant management.

METHODS

A search of relevant databases and bibliographies until February 2008 yielded 150 citations of which 31 were potentially relevant and 11 met all criteria. The total estimates of the differences in pregnancy rates per couple were calculated with weights equal to the inverse variance. The primary analysis was a categorical meta-analysis by the type of control treatment (TI or expectant management).

RESULTS

In 11 trials with 13 comparisons of IUI and intercourse among 1329 couples with subfertility, the average difference in pregnancy rate between IUI and controls was 6.1% in trials with TI and 3.9% in trials with expectant management, as the control. The adjusted indirect estimate of the difference between the types of control groups was 2.8% (95% CI -6.3, 10.7). The difference by type of control treatment was not significant, neither in the 11 most relevant trials (P = 0.82), nor in a broader group of 19 trials and 2512 patients (P = 0.20).

CONCLUSIONS

The additional benefit accruing to IUI, where TI is the control, is not significant, but it is consistent with the possibility that pregnancy may be less likely in TI controls than in expectant management controls.

Relationship between follicle number and (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVES

The goal of this study was to determine the relationship between the number of mature ovarian follicles and the (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination.

STUDY DESIGN

A total of 2463 intrauterine insemination cycles performed during a natural cycle (n = 118), or after controlled ovarian hyperstimulation with either clomiphene citrate (n = 663) or with gonadotrophins (n = 1682) were reviewed to assess the impact of the type of stimulation and the number of follicles 14 mm or larger on the (multiple) live birth rate per cycle.

RESULTS

The live birth rate after intrauterine insemination was significantly higher (P = .02) after stimulation with gonadotrophins (13%) than after clomiphene cirate (8%) if only 1 follicle 14 mm or larger was present. If 2 or more follicles were present, there was no statistically significant difference between both stimulation methods.

CONCLUSION

Treatment of intrauterine insemination with gonadotrophin is effective with an acceptable (multiple) live birth rate when 1 or 2 follicles 14 mm or larger are present.

Intra-uterine insemination for male subfertility

BACKGROUND

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with ovarian hyperstimulation (OH) has been subject of discussion. Although the treatment itself is less invasive and expensive than others, its efficacy has not been proven. Furthermore, the adverse effects of OH such as ovarian hyperstimulation syndrome (OHSS ) and multiple pregnancy are a concern.

OBJECTIVES

The aim of this review was to determine whether for couples with male subfertility, IUI improves the live birth rates or ongoing pregnancy rates compared with timed intercourse (TI), with or without OH.

SEARCH STRATEGY

We searched the Cochrane Menstrual and Disorders Subfertility Group Trials Special Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, 2006, issue 3), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), SCIsearch and the reference lists of articles. We hand searched abstracts of the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology. Authors of identified articles were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCT's) with at least one of the following comparisons were included: 1) IUI versus TI or expectant management both in natural cycles 2) IUI versus TI both in cycles with OH 3) IUI in natural cycles versus TI + OH 4) IUI + OH versus TI in natural cycles 5) IUI in natural cycles versus IUI + OH. Couples with abnormal sperm parameters only were included.

DATA COLLECTION AND ANALYSIS

Two co-reviewers independently performed quality assessment and data extraction. Where possible data were pooled, and a meta-analysis was performed. Sensitivity and subgroup analyses were carried out where possible and appropriate.

MAIN RESULTS

Three trials of parallel design, and five trials of cross-over design with pre-cross-over data were included in the meta-analysis. Three compared IUI with TI both in stimulated cycles. The remaining four of these studies compared IUI versus IUI + OH . Three studies reported on our main outcome of interest live birth rate per couple. For the comparison IUI versus TI both in natural cycles no evidence of difference between the probabilities of pregnancy rates per woman after IUI compared with TI was found (Peto OR 5.3, 95% CI 0.42 to 67). No statistically significant of difference between pregnancy rates (PR) per couple for IUI + OH versus IUI could be found (Peto OR 1.47, 95% CI 0.92 to 2.37). For the comparison IUI versus TI both in stimulated cycles there was no evidence of statistically significant difference in pregnancy rates per couple either (Peto OR 1.67, 95% CI 0.83 to 3.37). There were insufficient data available for adverse outcomes such as OHSS, multiple pregnancy, miscarriage rate and ectopic pregnancy to perform a statistical analysis. For the other two comparisons no RCT's were found which reported pregnancy rates per couple. A further 10 studies which included one of the comparisons of interests were found. Since these studies reported pregnancy rates per cycle only these data could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence of effectiveness to recommend or advise against IUI with or without OH above TI, or vice versa. Large, high quality randomised controlled trials, comparing IUI with or without OH with pregnancy rate per couple as the main outcome of interest are lacking. There is a need for such trials since firm conclusions cannot be drawn yet.

Intra-uterine insemination for male subfertility

BACKGROUND

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with ovarian hyperstimulation (OH) has been subject of discussion. Although the treatment itself is less invasive and expensive than others, its efficacy has not been proven. Furthermore, the adverse effects of OH such as ovarian hyperstimulation syndrome (OHSS ) and multiple pregnancy are a concern.

OBJECTIVES

The aim of this review is to determine whether for couples with male subfertility, IUI improves the live birth rates or ongoing pregnancy rates compared with timed intercourse (TI), with or without OH.

SEARCH STRATEGY

We searched the Cochrane Menstrual and Disorders Subfertility Group Trials Special Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, 2006, issue 3), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), SCIsearch and the reference lists of articles. We hand searched abstracts of the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology. Authors of identified articles were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCT's) with at least one of the following comparisons were included: 1) IUI versus TI or expectant management both in natural cycles 2) IUI versus TI both in cycles with OH 3) IUI in natural cycles versus TI + OH 4) IUI + OH versus TI in natural cycles 5) IUI in natural cycles versus IUI + OH Couples with abnormal sperm parameters only were included.

DATA COLLECTION AND ANALYSIS

Two co-reviewers independently performed quality assessment and data extraction. Where possible data were pooled, and a meta-analysis was performed. Sensitivity and subgroup analyses were carried out where possible and appropriate.

MAIN RESULTS

Three trials of parallel design, and five trials of cross-over design with pre-cross-over data were included in the meta-analysis. Three compared IUI with TI both in stimulated cycles. The remaining four of these studies compared IUI versus IUI + OH . Three studies reported on our main outcome of interest live birth rate per couple. For the comparison IUI versus TI both in natural cycles no evidence of difference between the probabilities of pregnancy rates per woman after IUI compared with TI was found (Peto OR 5.3, 95% CI 0.42 to 67). No statistically significant of difference between pregnancy rates (PR) per couple for IUI + OH versus IUI could be found (Peto OR 1.47, 95% CI 0.92 to 2.37). For the comparison IUI versus TI both in stimulated cycles there was no evidence of statistically significant difference in pregnancy rates per couple either (Peto OR 1.67, 95% CI 0.83 to 3.37). There were insufficient data available for adverse outcomes such as OHSS, multiple pregnancy, miscarriage rate and ectopic pregnancy to perform a statistical analysis. For the other two comparisons no RCT's were found which reported pregnancy rates per couple. A further 10 studies which included one of the comparisons of interests were found. Since these studies reported pregnancy rates per cycle only these data could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence of effectiveness to recommend or advise against IUI with or without OH above TI, or vice versa. Large, high quality randomised controlled trials, comparing IUI with or without OH with pregnancy rate per couple as the main outcome of interest are lacking. There is a need for such trials since firm conclusions cannot be drawn yet.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rates.

OBJECTIVES

To determine whether for couples with unexplained subfertility IUI improves the live birth rate compared with timed intercourse (TI), both with and without ovarian hyperstimulation.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorder and Subfertility Group Trials Register (searched March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to November 2005), EMBASE (1980 to November 2005), SCIsearch and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data.

SELECTION CRITERIA

Truly randomised controlled trials (RCTs) with at least one of the following comparisons were included: --IUI versus TI, both in a natural cycle; --IUI versus TI, both in a stimulated cycle; --IUI in a natural cycle versus IUI in a stimulated cycle; --IUI with OH versus TI in natural cycle; --IUI in a natural cycle versus TI with OH. Only couples with unexplained subfertility were included.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two review authors. Outcomes were extracted and the data were pooled. Subgroup analyses and sensitivity analyses were done where possible.

MAIN RESULTS

In the six trials where IUI was compared with TI, both in stimulated cycles, there was evidence of an increased chance of pregnancy (six RCTs, 517 women: OR 1.68, 95% CI 1.13 to 2.50). A significant increase in pregnancy rate was also found for women where IUI with OH was compared with IUI in a natural cycle (three RCTs, 415 women: OR 2.33, 95% CI 1.46 to 3.71). However, the trials provided insufficient data to investigate the impact of IUI with or without OH on several important outcomes including live birth, multiple pregnancies, miscarriage and risk of ovarian hyperstimulation. There was no evidence of a difference in pregnancy rate for IUI with OH compared with TI in a natural cycle (one RCT, 51 women: OR 4.05, 95% CI 0.39 to 41.87). No RCTs were found for the other two comparisons.

AUTHORS' CONCLUSIONS

There is evidence that IUI with OH increases the live birth rate compared to IUI alone. The likelihood of pregnancy was also increased for treatment with IUI compared to TI both in stimulated cycles. There is insufficient data on multiple pregnancies and other adverse events for treatment with OH. Therefore, couples should be fully informed about the risks of IUI and OH as well as alternative treatment options.

Should We Continue Performing Intrauterine Inseminations in the Year 2004?

This review summarizes the existing evidence regarding intrauterine insemination (IUI) as a treatment for cervical hostility, male and unexplained subfertility. IUI in natural cycles has been proven effective in patients with cervical hostility and moderate male subfertility. IUI in cycles with mild ovarian hyperstimulation (MOH) should be the treatment of choice in couples with mild male subfertilty (average total motile sperm count above 10 million) and unexplained subfertilty. When MOH is applied, gonadotropins have been proven more effective compared with clomiphene citrate. Further large trials comparing clomiphene citrate with gonadotropins are mandatory. Prevention of multiple pregnancies in MOH/IUI programs is of paramount importance. A strategy with a low-dose step-up protocol and strict cancellation criteria is proposed. When multiple pregnancies are kept to a minimum, MOH/IUI is more cost-effective compared with in vitro fertilization and embryo transfer. Future research should focus on prediction models to predict the outcome of MOH/IUI treatment for individual couples before starting treatment.

Human chorionic gonadotropin administration is associated with high pregnancy rates during ovarian stimulation and timed intercourse or intrauterine insemination

BACKGROUND

There are different factors that influence treatment outcome after ovarian stimulation and timed-intercourse or intrauterine insemination (IUI). After patient age, it has been suggested that timing of insemination in relation to ovulation is probably the most important variable affecting the success of treatment. The objective of this study is to study the value of human chorionic gonadotropin (hCG) administration and occurrence of luteinizing hormone (LH) surge in timing insemination on the treatment outcome after follicular monitoring with timed-intercourse or intrauterine insemination, with or without ovarian stimulation.

METHODS

Retrospective analysis of 2000 consecutive completed treatment cycles (637 timed-intercourse and 1363 intrauterine insemination cycles). Stimulation protocols included clomiphene alone or with FSH injection, letrozole (an aromatase inhibitor) alone or with FSH, and FSH alone. LH-surge was defined as an increase in LH level > or =200% over mean of preceding two days. When given, hCG was administered at a dose of 10,000 IU. The main outcome was clinical pregnancy rate per cycle.

RESULTS

Higher pregnancy rates occurred in cycles in which hCG was given. Occurrence of an LH-surge was associated with a higher pregnancy rate with clomiphene treatment, but a lower pregnancy rate with FSH treatment.

CONCLUSIONS

hCG administration is associated with a favorable outcome during ovarian stimulation. Awaiting occurrence of LH-surge is associated with a better outcome with CC but not with FSH treatment.

[Is the limitation to 6 cycles of insemination with donor sperm justified?]

OBJECTIVE

To evaluate the effect of the limitation at 6 cycles of artificial insemination in a program of sperm donation.

STUDY DESIGN

266 couples included in a program of sperm donation underwent 1,354 cycles including 532 intracervical insemination (ICI), 678 intrauterine insemination (IUI) and 133 in vitro fertilization (IVF).

RESULTS

The birth rate by cycle was 10.8% in ICI, 18% in IUI, 21.9% in IVF. The risk of multiple pregnancies was 0% in ICI, 13% in IUI, 33% in IVF. The authors feign then two strategies, the first one with 6 ICI followed by 6 IUI, and the other one with 6 IUI alone. The birth rate, the risk of multiple pregnancies and the cost of these two strategies is discussed.

CONCLUSION

The restriction to 6 IA Cycles in a donor semen program does not change the birth rate, but increases the multiple pregnancy rate and the cost of the treatment of these patients.

Sperm motility in the semen analysis affects the outcome of superovulation intrauterine insemination in the treatment of infertile Asian couples with male factor infertility

OBJECTIVE

To ascertain the relationship between the initial and unprocessed sperm parameters and pregnancy rates in SOIUI, for Asian couples with male factor infertility.

DESIGN

Retrospective study.

SETTING

A large government tertiary-care women's hospital with 15,000 deliveries per year.

POPULATION

One thousand four hundred and seventy nine couples undergoing 2846 cycles of SOIUI.

METHODS

All couples enrolled in the SOIUI programme were analysed, comparing initial sperm parameters and the post-processed total motile sperm, against pregnancy rates per cycle.

MAIN OUTCOME MEASURES

Pregnancy rates in relation to initial sperm parameters and post-processed total motile sperm.

RESULTS

Ninety-three percent of the couples had male factor infertility. The average normal forms for these men was 14.7%. Overall pregnancy rate was 12.1% per completed SOIUI cycle. We found a significant drop in pregnancy rates if the percentage of motile sperms in the unprocessed sperm sample fell below 30%. We also found that insemination of at least 1 million motile sperm resulted in a significant increase in pregnancy rates.

CONCLUSIONS

We recommend SOIUI as an effective treatment of suitable couples with male infertility, before embarking on IVF. However, if the initial percentage of motile sperm fell below 30%, or if after processing, the total motile sperm count was fewer than 1 million, these couples should consider in vitro fertilisation.

A simple method for fallopian tube sperm perfusion using a blocking device in the treatment of unexplained infertility

OBJECTIVE

To evaluate the efficacy of fallopian sperm perfusion (FSP) using a new method similar to the FAST system in comparison with standard intrauterine insemination (IUI) in patients with unexplained infertility.

DESIGN

Prospective, randomized, controlled study.

SETTING

Assisted conception service in a University Hospital.

PATIENT(S)

Women with unexplained infertility undergoing controlled ovarian hyperstimulation (COH).

INTERVENTION(S)

After hCG administration, patients were randomized to either standard IUI or FSP. The women received the same treatment in the first and all subsequent cycles. A maximum of three cycles was performed. Intrauterine insemination was performed using a standard method, and fallopian sperm perfusion was performed using a commercial device for hysterosalpingography and tubal hydropertubation.

MAIN OUTCOME MEASURE(S)

Clinical and ongoing pregnancy rates.

RESULT(S)

A total of 132 cycles was completed: 66 IUI cycles and 66 FSP cycles. In the IUI group, there were 5 ongoing pregnancies, giving a pregnancy rate of 7.6 per cycle and 15.6% per patient; in the FSP group, 14 ongoing pregnancies occurred, giving a pregnancy rate of 21.2% per cycle and 42.4% per patient. The prevalence of multiple pregnancies, miscarriages and ectopic pregnancies was similar in the two insemination groups. Fallopian sperm perfusion was easy to perform, and no case of sperm reflux was observed. The procedure was well tolerated and no complications were observed. The costs were comparable with standard IUI.

CONCLUSION(S)

In the treatment of couples with unexplained infertility, the method for fallopian sperm perfusion described yields higher pregnancy rates than IUI, with no significant increase in costs or complications. However, these results need to be confirmed in larger studies before replacing IUI with FSP as standard practice.

Intrauterine insemination with donor semen. An evaluation of prognostic factors based on a review of 1131 cycles

OBJECTIVE

To identify prognostic factors influencing the outcome of infertility treatment using intrauterine insemination with donor semen (IUI-D).

DESIGN

Retrospective study of all patients undergoing IUI-D between August 1st, 1990 and July 31st, 1998.

SETTING

University-affiliated infertility clinic.

PATIENTS

Three hundred and five couples undergoing 1131 IUI-D treatment cycles.

MAIN OUTCOME MEASURES

Type of hormonal treatment, number of follicles, length of follicular phase, endometrial pattern, female age, infertility diagnosis and semen quality related to clinical pregnancy rate, cumulative birth rate and multiple gestations.

RESULTS

Throughout the nine year period the overall clinical pregnancy rate per cycle was 22.3%, with an increase from 12.9% in 1990 to 34.6% in 1998. The multiple birth rate was 20.6%. The birth rate per couple was 61.1% after a mean of 3.2 treatment cycles. The pregnancy rate was highest in the first treatment cycle and the cumulative birth rate rose only slightly after the sixth treatment cycle. The following parameters were positively and significantly correlated to a successful outcome of IUI-D: i) the first treatment cycle - compared to the following up to six treatment cycles; ii) number of mature follicles - more than one - at the time of insemination, however, with an unacceptable high rate of multiple pregnancies when more than 3 mature follicles were present; iii) time of insemination after the 12th day in the cycle; iv) insemination after ovulation has occurred and; v) female age under 30 years.

CONCLUSIONS

IUI-D is a simple and inexpensive treatment giving acceptable pregnancy rates for up to six treatment cycles if at least 2 mature follicles have developed at the time of insemination, which implies that hormonal ovarian stimulation and induction of ovulation is used, and ovulation has occurred at the time of insemination, which ought to take place after cycle day (cd) 12 with at least two million motile spermatozoa.

Relationship of follicle numbers and estradiol levels to multiple implantation in 3,608 intrauterine insemination cycles

OBJECTIVE

To determine the relationship of follicle numbers and estradiol (E(2)) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles.

DESIGN

Fifteen-year prospective study.

SETTING

Private infertility clinic.

PATIENT(S)

Women who underwent 3608 cycles of husband or donor intrauterine insemination (IUI).

INTERVENTION(S)

Ovulation induction (OI) with CC, hMG, or CC+hMG.

MAIN OUTCOME MEASURE(S)

Pregnancy and multiple implantations.

RESULT(S)

Triplet and higher-order implantations-but not twin implantations-were related to age, E(2) levels, and number of follicles > or = 12 mm and > or = 15 mm, but not number of follicles > or = 18 mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were > or = 12 mm, in CC, hMG, and CC+hMG cycles, and when E(2) was > or = 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older, pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were > or = 12 mm, or E(2) levels were >1000 pg mL, whereas 3 or more implantations were not significantly increased.

CONCLUSIONS

Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are > or = 12 mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.

Comparison of intrauterine insemination with timed intercourse in superovulated cycles with gonadotropins: a meta-analysis

OBJECTIVE

To compare timed intercourse and IUI with the husband's sperm in patients with unexplained infertility who are undergoing superovulation with gonadotropins.

DESIGN

Meta-analysis. All published reports of randomized, prospective studies with an English-language abstract extracted from MEDLINE were analyzed. A crossover search was done from the papers obtained.

SETTING

Academic center.

PATIENT(S)

Couples with unexplained infertility.

INTERVENTION(S)

Meta-analysis of studies evaluating patients superovulated with gonadotropins and randomized for timed intercourse or IUI.

MAIN OUTCOME MEASURE(S)

Pregnancy rates (PRs) were obtained. The common odds ratio (OR) and 95% confidence intervals (95% CI) were calculated.

RESULT(S)

There were 49 pregnancies in 431 cycles of timed intercourse (11.37%), whereas there were 110 pregnancies in 549 cycles of IUI (20.04%). The PRs for IUI were significantly increased compared with those for timed intercourse in superovulation cycles (common OR = 1.84; 95% CI = 1.30-2.62).

CONCLUSION(S)

On the basis of the meta-analysis of 980 cycles in randomized and prospective studies, a patient's chances of becoming pregnant are greater with IUI with her husband's sperm than with timed intercourse in cycles superovulated with gonadotropins.

The impact of sperm morphology evaluated by strict criteria on intrauterine insemination success

OBJECTIVE

To determine the relationship between IUI success and the level of morphologically normal sperm, evaluated using strict criteria, in the raw semen.

DESIGN

Evaluation of semen quality characteristics and pregnancy results for 538 stimulated IUI cycles.

SETTING

University medical center infertility clinic.

PATIENT(S)

Women undergoing IUI with their partner's semen as treatment for infertility (n = 193).

INTERVENTION(S)

Ovulation induction using clomiphene citrate, hMG, or both; preparation of raw semen using wash and swim-up or Percoll; deposition of prepared semen at the uterine fundus.

MAIN OUTCOME MEASURE(S)

Pregnancy status after IUI. Percentage morphologically normal sperm in raw semen, evaluated using strict criteria. Sperm concentration and percentage motile sperm in raw and prepared semen.

RESULT(S)

Pregnancy rates (PRs) per cycle were not different when the percentage of morphologically normal sperm in raw semen was < 5%, 5% to 9%, 10% to 19%, 20% to 29%, and > or = 30% (6.5% +/- 3.9%, 13.6% +/- 3.2%, 8.8% +/- 2.4%, 7.1% +/- 2.5%, and 9.7% +/- 3.3%, respectively). Pregnancy rates did not differ among age groups, infertility diagnoses, ovarian stimulation protocols, or semen preparation methods.

CONCLUSION(S)

The percentage of morphologically normal sperm in the raw semen, as judged by strict criteria, did not affect IUI PR. Intrauterine insemination appears to be a successful treatment modality for male factor infertility, even when the percentage of morphologically normal sperm in raw semen is very low.

Pregnancy rates in gonadotrophin stimulated cycles with timed intercourse or intrauterine insemination for the treatment of male subfertility

OBJECTIVE

To compare the pregnancy rates achieved by intrauterine insemination or timed intercourse in gonadotrophin stimulated cycles in couples whose only detectable abnormality was poor sperm quality.

DESIGN

Sixty-two couples with primary or secondary infertility due to male factor entered the study. The 62 couples were randomly equally divided into two groups. Each group began one of the two treatment modalities (controlled ovarian hyperstimulation in conjunction with timed intercourse or intrauterine insemination) for three consecutive cycles and then switched to the alternative treatment after one rest cycle, if pregnancy was not achieved.

RESULTS

Five pregnancies (3.9%) were achieved after 128 cycles with timed intercourse and 15 pregnancies (11.5%) after 130 cycles with intrauterine insemination. The difference was found to be statistically significant (P < 0.05).

CONCLUSION

We suggest that intrauterine insemination during hMG stimulated cycles improves the pregnancy rates of couples whose only detectable abnormality is poor sperm quality.

Ovulation induction with gonadotropins as sole treatment in infertile couples with open tubes: a randomized prospective comparison between intrauterine insemination and timed vaginal intercourse

OBJECTIVE

To assess if ovulation induction with gonadotropins alone is an appropriate treatment in couples affected by unexplained and mild male factor-related infertility and if the concomitant IUI improves the pregnancy rate (PR).

DESIGN

Prospective and randomized trial.

SETTING

Infertility Centre of Department of Obstetrics and Gynecology of the University of Cagliari, Cagliari, Italy.

PATIENTS

Two hundred couples affected by unexplained or mild male factor-related infertility were assigned randomly to one of two treatment groups: group A (n = 100), treated with three consecutive cycles of ovulation induction with gonadotropins associated with timed vaginal intercourse; group B (n = 100), treated with three consecutive cycles of ovulation induction with gonadotropins associated with IUI.

MAIN OUTCOME MEASURE

Pregnancy rate.

RESULTS

The PRs obtained with ovulation induction with gonadotropins associated with IUI were similar to those obtained with ovulation induction with gonadotropins associated with timed vaginal intercourse.

CONCLUSION

Ovulation induction with gonadotropins alone may be as effective as ovulation induction with gonadotropins associated with IUI in couples with unexplained and mild male factor infertility and can represent the initial treatment option for its minimal invasivity and reduced cost and organizational problems.

Controlled ovarian hyperstimulation with or without intrauterine insemination for the treatment of unexplained infertility

OBJECTIVE

To evaluate whether there are any benefits from intrauterine insemination (IUI) as opposed to timed intercourse (TI) in stimulated ovarian cycles in couples with longstanding, unexplained infertility.

METHODS

Forty-six couples with diagnoses of unexplained infertility were evaluated in a crossover study after a total of 141 cycles. Sixty-seven cycles were with IUI after controlled ovarian hyperstimulation (COH) while 74 cycles were after COH and TI.

RESULTS

The pregnancy rate after COH/TI was 16.7% and after COH/IUI 45.2%. Cycle fecundity however was 8.9% after COH/TI and 25.7% after COH/IUI, which is a statistically significant difference (P < 0.05).

CONCLUSIONS

A trial of human menopausal gonadotropin and IUI is justified in couples with prolonged infertility of unknown cause.

A three step protocol for the treatment of idiopathic subfertility

650 couples with idiopathic subfertility (mean duration: 5.7 year, range 2-21 years) were treated during 2870 cycles by three assisted conception methods (each involving mild ovarian stimulation): I timed intercourse (TI), II intrauterine insemination (IUI). III in vitro fertilization/embryo transfer (IVF/ET). Treatment started with TI in most cases and then changed to IUI after three to six cycles. Couples who failed to conceive were treated after another 3-9 cycles by IVF/ET. An overall cumulative pregnancy rate of 80.2% was reached after 18 treatment months. The pregnancy rates per treatment cycle were: TI 5.3%, IUI 6.9%, IVF/ET 15.8% (per oocyte retrieval).

Therapeutic intrauterine insemination improves with gonadotropin ovarian stimulation

Therapeutic intrauterine insemination (IUI) is frequently used as a first line of treatment of infertility. The reported results vary, depending on the indication and the use of ovulation simulation protocols. In the present study, we review the experience at the Jones Institute for Reproductive Medicine in Virginia from January 1989 to January 1991. The patients were preferentially treated with ovulation induction with gonadotropins. With the addition of gonadotropin stimulation, the total and term pregnancy rates per cycle were 14% and 11%, respectively, including all etiologic factors. These rates were improved over the 3% and 2.6% rates reported in our previous study in which ovarian stimulation was not generally used. In male factor patients, the term pregnancy rate was 9%, higher than the 4% term pregnancy rate reported in our previous study. In the present series, morphology was the only severely impaired parameter. The term pregnancy rate was 11% for patients with ovulatory dysfunction, 10% for those with cervical factor, and 10.5% for those with unexplained infertility.

Intrauterine insemination after ovarian stimulation as a treatment for subfertility because of subnormal semen: a prospective randomized controlled trial

OBJECTIVE

To determine whether intrauterine insemination (IUI) after ovarian stimulation with human menopausal gonadotropin (hMG) gives a better pregnancy rate (PR) than natural intercourse in couples with subfertility because of subnormal semen.

DESIGN

Prospective randomized controlled trial.

SETTING

University based subfertility clinic.

PATIENTS

Couples with subnormal semen as the only identifiable cause of subfertility.

INTERVENTIONS

In control cycles, the couples had natural intercourse. In IUI cycles, IUI was performed after ovarian stimulation with hMG and human chorionic gonadotropin.

MAIN OUTCOME MEASURE

The clinical PRs and complications of IUI cycles and control cycles were compared.

RESULTS

There were six clinical pregnancies in the 42 IUI cycles, whereas there was no clinical pregnancy in the 42 control cycles. The clinical PR in IUI cycles (14.3% per cycle) was significantly higher than that in control cycles (0%). Six patients (14.3%) developed moderate degree of ovarian hyperstimulation syndrome in IUI cycles.

CONCLUSION

Intrauterine insemination after ovarian stimulation with hMG is useful in treatment of subfertile couples with subnormal semen.