A prospective randomized trial of artificial insemination versus intercourse in cycles stimulated with human menopausal gonadotropin or clomiphene citrate*†*Supported by grant no. B91-17X-03495-20A from The Swedish Medical Research Council, Stockholm Sweden.†Presented in part at the 13th World Congress of Obstetrics and Gynecology, Singapore, September 15 to 20, 1991

IUI for unexplained infertility-a network meta-analysis

BACKGROUND

IUI for unexplained infertility can be performed in a natural cycle or in combination with ovarian stimulation. A disadvantage of ovarian stimulation is an increased risk of multiple pregnancies with its inherent maternal and neonatal complication risks. Stimulation agents for ovarian stimulation are clomiphene citrate (CC), Letrozole or gonadotrophins. Although studies have compared two or three of these drugs to each other in IUI, they have never been compared to one another in one analysis.

OBJECTIVE AND RATIONALE

The objective of this network meta-analysis was to compare the effectiveness and safety of IUI with CC, Letrozole or gonadotrophins with each other and with natural cycle IUI.

SEARCH METHODS

We searched PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL and the Clinical Trial Registration Database indexed up to 16 August 2018. We included randomized controlled trials that compared a stimulation regimen with CC, Letrozole or gonadotrophins to each other or to natural cycle IUI among couples with unexplained infertility. We performed the network meta-analysis within a multivariate random effects model.

OUTCOMES

We identified 26 studies reporting on 5316 women. The relative risk (RR) for live birth/ongoing pregnancy rates comparing IUI with CC to natural cycle IUI was 1.05 (95% CI 0.63-1.77, low quality of evidence), while comparing IUI with Letrozole to natural cycle IUI was 1.15 (95% CI 0.63-2.08, low quality of evidence) and comparing IUI with gonadotrophins to natural cycle IUI was 1.46 (95% CI 0.92-2.30, low quality of evidence). The RR for live birth/ongoing pregnancy rates comparing gonadotrophins to CC was 1.39 (95% CI 1.09-1.76, moderate quality of evidence), comparing Letrozole to CC was 1.09 (95% CI 0.76-1.57, moderate quality of evidence) and comparing Letrozole to gonadotrophins was 0.79 (95% CI 0.54-1.15, moderate quality of evidence). We did not perform network meta-analysis on multiple pregnancy due to high inconsistency. Pairwise meta-analyses showed an RR for multiple pregnancy rates of 9.11(95% CI 1.18-70.32) comparing IUI with gonadotrophins to natural cycle IUI. There was no data available on multiple pregnancy rates following IUI with CC or Letrozole compared to natural cycle IUI. The RR for multiple pregnancy rates comparing gonadotrophins to CC was 1.42 (95% CI 0.68-2.97), comparing Letrozole to CC was 0.97 (95% CI 0.47-2.01) and comparing Letrozole to gonadotrophins was 0.29 (95% CI 0.14-0.58).In a meta-analysis among studies with adherence to strict cancellation criteria, the RR for live births/ongoing pregnancy rates comparing gonadotrophins to CC was 1.20 (95% CI 0.95-1.51) and the RR for multiple pregnancy rates comparing gonadotropins to CC was 0.80 (95% CI 0.38-1.68).

WIDER IMPLICATIONS

Based on low to moderate quality of evidence in this network meta-analysis, IUI with gonadotrophins ranked highest on live birth/ongoing pregnancy rates, but women undergoing this treatment protocol were also at risk for multiple pregnancies with high complication rates. IUI regimens with adherence to strict cancellation criteria led to an acceptable multiple pregnancy rate without compromising the effectiveness. Within a protocol with adherence to strict cancellation criteria, gonadotrophins seem to improve live birth/ongoing pregnancy rates compared to CC. We, therefore, suggest performing IUI with ovarian stimulation using gonadotrophins within a protocol that includes strict cancellation criteria. Obviously, this ignores the impact of costs and patients preference.

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.

Ovarian stimulation and intrauterine insemination at the quarter centennial: implications for the multiple births epidemic

Ovarian stimulation and intrauterine insemination (OS/IUI), a mainstay of current infertility therapy and a common antecedent to IVF, is a significant driver of the multiple births epidemic. Redress of this challenge, now marking its quarter centennial, will require a rethinking of current practice patterns. Herein we explore prospects for prevention, mitigation, and eventual resolution. We conclude that the multiple births attributable to OS/IUI may not be entirely preventable but that the outlook for their mitigation is promising, if in need of solidification. Specifically, we observe that low-dose (≤ 75 IU) gondotropin, clomiphene, and especially off-label letrozole regimens outperform high-dose (≥ 150 IU) gonadotropin counterparts in the gestational plurality category while maintaining comparable per-cycle pregnancy rates. Accordingly we recommend that, subject to appropriate exceptions, high-dose gonadotropin regimens be used sparingly and that whenever possible they be replaced with emerging alternatives. Finally, we posit that OS/IUI is not likely to be superseded by IVF absent further commoditization and thus greater affordability.

A prospective randomized noninferiority study comparing recombinant FSH and highly purified menotropin in intrauterine insemination cycles in couples with unexplained infertility and/or mild-moderate male factor

OBJECTIVE

To demonstrate the noninferiority of highly purified menotropin (HP-hMG) compared with recombinant FSH (rFSH) regarding clinical pregnancy rate (PR) in intrauterine insemination (IUI) cycles.

DESIGN

Prospective randomized noninferiority trial.

SETTING

Unit of physiopathology of human reproduction, university hospital.

PATIENT(S)

Five hundred twenty-three patients with unexplained infertility or mild male infertility undergoing controlled ovarian hyperstimulation for IUI.

INTERVENTION(S)

Patients were randomized for treatment with rFSH (262 patients) or HP-hMG (261 patients). Insemination was performed 34-36 hours after hCG injection.

MAIN OUTCOME MEASURE(S)

The primary outcome was clinical pregnancy rate (PR). The secondary outcome was the number of interrupted cycles for high risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy.

RESULT(S)

The clinical PR was 19.7% (95% confidence interval [CI] 15.3%-25.1%) in the HP-hMG group and 21.4% (95% CI 16.9%-26.8%) in the rFSH group [absolute difference -1.7% (95% CI -8.6%-5.2%)]; therefore, the noninferiority was demonstrated. The number of interrupted cycles for OHSS risk and multiple pregnancy was significantLy higher in the rFSH group, 8.4% (95% CI 5.6%-12.4%) than in the HP-hMG group 1.2% (95% CI 0.4%-3.3%) [absolute difference -7.27% (95% CI -11.3 to -3.7)].

CONCLUSION(S)

HP-hMG is not inferior compared with rFSH regarding clinical PR.

RETRACTED: Clomiphene citrate or aromatase inhibitors for superovulation in women with unexplained infertility undergoing intrauterine insemination: a prospective randomized trial

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the ASRM Publication Committee Several reports of randomized clinical trials were recently the subject of an investigation conducted by the publications committee of the ASRM. The committee reviewed concerns related to the validity of data reported in those reports. The committee noted significant duplication of data reported in this manuscript with data reported in another journal (PMID: 17582406; https://doi.org/10.1016/j.fertnstert.2007.02.062) pertaining to a different study group that could not be explained. As we cannot vouch for the validity of the data, we have issued a retraction of this paper.

EFFECTS OF SEMEN CHARACTERISTICS ON IUI COMBINED WITH MILD OVARIAN STIMULATION

To determine the influence of sperm parameters inseminated on the outcome of intrauterine insemination (IUI) in patients undergoing ovarian stimulation with clomiphen citrat (CC) or human menopausal gonadotropin (HMG) therapy, a retrospective review was performed for 2 years on data from the IUI program. 190 couples underwent a total of 268 IUI cycles in which CC or HMG was used for ovulation induction. The initial sperm concentration (mil/ml), motility (percent), preprocessing total motile sperm (TMS) count (million), fast motile sperm (percent) and postprocessing sperm concentration (mil/ml), motility (percent), TMS count, fast motile sperm (percent), sperm morphology, hypoosmotic swelling (HOS) scores, semen leuocytes, and bacteria were analyzed. 268 inseminations were followed by a pregnancy rate of 12% and couple pregnancy rate of 17%. On multivariable logistic regression analysis, total motile sperm (TMS) count, percent motility, and percent of fast motile sperm were independent prognostic factors of fertility. The impact of the preprocessing and postprocessing sperm parameters on pregnancy outcome after IUI was evaluated. There was a trend toward an increasing percent of conception with increasing TMS count, motility, and percent of fast motile sperm. The TMS count, motility and percent of fast motile sperm independently predict success with IUI. Patients with original sperm motility > or = 30% had a higher cumulative pregnancy rate (74%) than patient with motility < 30% (p < 0.005). Pregnancy rate increased 4 times with motility of > or = 30%.

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.

Effect of heat-induced hypermotility on pregnancy rate in intrauterine insemination for male factor infertility associated with asthenospermia: a prospective, randomized, controlled study

OBJECTIVE

To assess the effect of mild heat for the enhancement of sperm fertilizing capacity in intrauterine insemination for male factor infertility associated with asthenospermia.

MATERIAL AND METHOD

Prospective, controlled, clinical study. Male factor infertility associated with asthenozoospermia was the criteria for inclusion. Ninety-seven couples were randomized to the study group while 100 couples were randomized to serve as the control group. Semen samples from the study group were processed with Percoll gradient and were left for incubation at 40 degrees C for 2 h. Semen samples from the control group were processed with Percoll gradient method and were incubated at 37 degrees C. Main outcome measure was the pregnancy rate.

RESULTS

The mean concentration of total motile sperm (TMS) in the study group was 11.20 +/- 4.22 x 10(6) (range 7-18) after wash with Percoll while was increased to 62.41 +/- 12.49 x 10(6) (range 44-71) after heat treatment. The mean concentration of TMS in the control group was 13.90 +/- 5.66 x 10(6) (range 8-19) after wash with Percoll while was increased to 17.73 +/- 3.67 x 10(6) (range 14-22) after incubation at 37 degrees C. The difference in TMS concentrations between the study and the control group after incubation at different temperatures was statistically significant (p < 0.005). There were 24 pregnancies in the study group, providing a pregnancy rate of 24.7%. In the control group eight pregnancies were achieved (8%) (p = 0.001).

CONCLUSION

Mild heat was found remarkably effective in asthenozoospermic males for increasing the concentration of inseminated total motile sperm and the pregnancy rate correspondingly.

A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility

BACKGROUND

Controlled ovarian hyperstimulation with intrauterine insemination (IUI) is a widely accepted treatment for unexplained and male subfertility. No consensus exists about the drug of first choice to be used as hyperstimulation. This randomized multicentre trial using a parallel design compares the efficacy of clomiphene citrate (CC) with that of recombinant FSH (rFSH).

METHODS

Couples with primary unexplained or male subfertility were randomized to receive CC or rFSH for ovarian hyperstimulation. The treatment was continued for up to four cycles unless pregnancy occurred. Cycles with more than three follicles were cancelled. Cumulative pregnancy rates and live birth rates were primary outcomes. Cancellation during treatment and multiple birth rates are secondary outcomes. Results were analysed following the intention-to-treat principle.

RESULTS

Seventy couples with male subfertility and 68 couples with unexplained subfertility were included. Seventy-one women received CC, and 67 received rFSH. Twenty-seven pregnancies were observed in the CC group (38%) and 23 in the rFSH group (34.3%) relative risk (RR) 1.11 [95% confidence interval (95% CI) 0.71-1.73]. The live birth rate was 28.2% (20/71) and 26.9% (18/67) for CC and rFSH, respectively, RR 1.05 (95% CI 0.61-1.80). Overall, the live birth rates per cycle were 10% for CC-stimulated and 8.7% for rFSH stimulated cycles. The total multiple pregnancy rate was 6.0%. Thirty-five cycles (8.6%) were cancelled because of four or more follicles (CC, n = 17; rFSH, n = 18).

CONCLUSIONS

In couples with primary unexplained or male subfertility participating in an IUI program, ovarian hyperstimulation can be achieved by CC or rFSH. No significant difference in live birth rates between CC and rFSH was observed. Being less expensive, CC seems the more cost-effective drug and therefore, can be offered as drug of first choice.

Catheter type does not affect the outcome of intrauterine insemination treatment: a prospective randomized study

OBJECTIVE

To compare the main outcome of IUI with the Gynetics catheter (Gynetics Medical Products, Hamont-Achel, Belgium) or the Makler cannula (Sefi-Medical Instruments, Haifa, Israel).

DESIGN

Prospective, randomized study.

SETTING

Infertility and endocrinology unit in a university hospital.

PATIENT(S)

Two hundred fifty-one infertile couples undergoing 784 consecutive IUI treatments.

INTERVENTION(S)

Patients were randomly assigned to undergo IUI treatment with either the Gynetics catheter (124 patients) or the Makler cannula (127 patients).

MAIN OUTCOME MEASURE(S)

Primary outcome measures were pregnancy and cumulative pregnancy rates. Secondary outcome measures were the ease of introduction of the catheter, the presence of bleeding, and semen regurgitation after removal of the catheter.

RESULT(S)

The use of the Gynetics catheter resulted in similar pregnancy (10.4% vs. 9.7%) and cumulative pregnancy rates (27.9% vs. 26.4%) as compared with the Makler cannula. Difficult introduction of the catheter was more frequent in the Gynetics group than in the Makler group (19.4% vs. 8.0%, respectively), but the frequency of bleeding did not differ between groups. Sample regurgitation was observed more often in the Makler group than in the Gynetics group (49.9% vs. 17.9%, respectively).

CONCLUSION(S)

A lower frequency of sperm regurgitation and a higher frequency of difficult introduction was observed when the Gynetics catheter was used. However, there was no significant difference in pregnancy rates with use of either the Gynetics catheter or the Makler cannula.

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.

Systematic review of the treatment of ovulatory infertility with clomiphene citrate and intrauterine insemination

BACKGROUND

Controlled ovarian hyperstimulation (COH) with clomiphene citrate (CC) combined with intrauterine insemination (IUI) is often used as treatment for ovulatory infertility which includes unexplained, male, cervical, endometriosis, and tubal infertility.

AIMS

To review the effectiveness of CC and IUI in ovulatory infertility.

METHODS

Systematic review of pertinent randomised controlled trials (RCT) using the bibliographic databases MEDLINE and EMBASE. References of selected articles identified were hand-searched for additional relevant citations.

RESULTS

Six published RCT were included in the overall review. Meta-analysis demonstrated a higher cycle pregnancy rate (CPR) with CC and IUI compared to timed intercourse in the natural cycle (P < 0.001 and odds ratio = 4.6, 95% CI = 1.9-11.3). Treatment with gonadotrophins and IUI results in a higher CPR compared to CC and IUI (P = 0.005 and odds ratio = 2.9, 95% CI = 1.3-6.2). Further RCT are required comparing CC and IUI with IUI or CC alone before one can make firm conclusions.

CONCLUSIONS

Clomiphene citrate combined with IUI is more effective than timed intercourse in the natural cycle at achieving pregnancy in couples with ovulatory infertility. However, treatment with gonadotrophins and IUI is superior to CC and IUI.

Intraperitoneal insemination in mammals: a review

This review focuses on factors associated with the development of intraperitoneal insemination in mammals. Findings to date indicate that fertility improves as the sperm cell concentration rises, but that the optimal sperm number differs in each species. Sperm washing before intraperitoneal insemination favours fertility. Peritoneal fluid shows a variable effect on spermatozoa, depending on the hormonal status of the female. The optimal time for insemination appears to be just prior to ovulation. The technique may be performed either through the abdominal or the vaginal wall. Verification of sperm deposition in the proximity of the ovaries improves fertility rates. Although associated with some risk of infection and an immune reaction against spermatozoa, the intraperitoneal technique rarely gives rise to severe anaphylactic shock, peritonitis, adhesion formation and the production of anti-sperm antibodies and these complications may be prevented by adequate sperm pretreatment and antibiotic therapy. The success of intraperitoneal insemination in humans, with results comparable with those of intrauterine insemination in the treatment of infertility, suggest the potential use of this technique in domestic mammals, especially in those in which intrauterine insemination poses practical difficulties. Some of the methods applied in human intraperitoneal insemination, such as confirming the position of the needle in the peritoneal cavity, and sperm pre-treatments might also improve results in domestic species. Conversely, the use of the animal model should help to develop some aspects of this technique in humans.

A randomized prospective study comparing pregnancy rates after clomiphene citrate and human menopausal gonadotropin before intrauterine insemination

OBJECTIVE

To determine whether hMG offers an advantage over clomiphene citrate (CC) in achieving pregnancy after IUI with husband's sperm.

DESIGN

Randomized prospective trial.

SETTING

Infertility patients in a university teaching hospital.

PATIENT(S)

Fifty-eight women under 39 years old undergoing ovulation induction before IUI.

INTERVENTION(S)

The women were assigned randomly to one of two treatment groups. Patients in group I (CCHH) received CC for the first two cycles and hMG for the last two cycles. Patients in group II (HHCC) received hMG for the first two cycles and CC for the last two cycles.

MAIN OUTCOME MEASURE(S)

Cycle fecundity rates for the two treatment modalities were compared statistically with use of life-table analysis.

RESULT(S)

Of the 174 cycles studied, overall cycle fecundity rate was 11.11 (9 of 81 cycles) in the CCHH group and 10.75 (10 of 93 cycles) in the HHCC group. The difference was not statistically significant. The cycle fecundity rate was 14.44% (13 of 90 cycles) for cycles with CC and 7.14% (6 of 84) with hMG. The difference was not statistically significant.

CONCLUSION(S)

These data suggest that CC is an effective alternative to hMG in the population examined.

Efficacy of treatment for unexplained infertility

OBJECTIVE

To analyze the efficacy and cost-effectiveness of alternative treatments for unexplained infertility.

DESIGN

Retrospective analysis of 45 published reports.

SETTING

Clinical practices.

PATIENT(S)

Couples who met criteria for unexplained infertility. Women with Stage I or Stage II endometriosis were included.

INTERVENTION(S)

Observation; clomiphene citrate (CC); gonadotropins (hMG); IUI; and GIFT and IVF.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate.

RESULT(S)

Combined pregnancy rates per initiated cycle, adjusted for study quality, were as follows: no treatment = 1.3%-4.1%; IUI = 3.8%; CC = 5.6%; CC + IUI = 8.3%; hMG = 7.7%; hMG + IUI = 17.1%; IVF = 20.7%; GIFT = 27.0%. The estimated cost per pregnancy was $10,000 for CC + IUI, $17,000 for hMG + IUI, and $50,000 for IVF.

CONCLUSION(S)

Clomiphene citrate + IUI is a cost-effective treatment for unexplained infertility. If this treatment fails, hMG + IUI and assisted reproduction are efficacious therapeutic options.

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.

A comparison of clomiphene citrate and human menopausal gonadotropin for use in conjunction with intrauterine insemination

OBJECTIVE

To compare the outcome of superovulation using clomiphene citrate (CC) versus hMG in conjunction with IUI.

DESIGN

Sequentially assigned, observational study. Couples initially were assigned to receive either CC or hMG for three cycles.

SETTING

The Clinical Outpatient Department of the Dartmouth-Hitchcock Medical Center.

PATIENT(S)

Eighty-three infertile couples.

INTERVENTION(S)

IUI with hMG use.

MAIN OUTCOME MEASURE(S)

Conception rate, term pregnancy rate (PR), and pregnancy complications, such as spontaneous miscarriage and multiple gestation.

RESULT(S)

Of 83 couples who underwent at least one treatment cycle, 29 (35%) conceived during the study period. The relative rate of conception for hMG versus CC was 2.08 (95% confidence interval [CI], 0.93 to 4.68). The relative term PR was 2.10 (95% CI, 0.77 to 5.73) for hMG versus CC. There was no difference in the miscarriage rate for hMG versus CC.

CONCLUSION(S)

Both the conception rate and the term PR were higher using hMG, compared with CC, in combination with IUI, and showed a trend toward statistical significance.

Clomiphene citrate ovulation induction in combination with a timed intrauterine insemination: the value of urinary luteinizing hormone versus human chorionic gonadotropin timing

OBJECTIVE

To evaluate the clinical pregnancy rates (PRs) in anovulatory, male factor, and unexplained infertility using clomiphene citrate (CC) with an IUI and to evaluate the difference in PRs between urinary LH testing and hCG administration for timing of the IUI.

DESIGN

Retrospective clinical study.

SETTING

Academic, tertiary care fertility center.

PATIENT(S)

One hundred thirty-eight couples (432 cycles) undergoing IUI with CC ovulation induction as a treatment for unexplained, anovulatory, or male factor infertility were selected.

INTERVENTION(S)

All women with unexplained or male factor infertility received CC at a dose of 50 mg/d, and those with anovulation received CC at a dose ranging from 50 to 200 mg/d. All women in the study received a single IUI either the morning after a urinary LH surge or 36 to 38 hours after an evening hCG injection.

MAIN OUTCOME MEASURE(S)

Clinical PR.

RESULT(S)

There were no differences in the clinical PRs between LH testing or hCG administration in any of the three groups. Clinical PRs were extremely low in the male factor infertility group regardless of the timing used.

CONCLUSION(S)

These data suggest that the success of IUI with CC is not dependent on the method used to establish the timing for the IUI. In couples undergoing IUI with CC, the use of urinary LH testing may result in lower costs by reducing patient visits and the midcycle ultrasound.

An open multicenter study to compare the efficacy of intraperitoneal insemination and intrauterine insemination following multiple follicular development as treatment for unexplained infertility

PURPOSE

This multicenter study was carried out to compare the efficacy of intrauterine insemination (IUI) and intraperitoneal insemination (IPI) associated with multiple follicular development as treatment for unexplained infertility.

METHOD

A total of 205 couples completed the trial. Sixty-seven couples underwent treatment with IPI (group A) and 138 couples underwent treatment with IUI (group B).

RESULTS

Clinical pregnancy was obtained in 23 couples in group A (pregnancy rate: 34.3%) and in 36 couples in group B (pregnancy rate: 26.1%). No significant difference was observed between group A and group B. As for the evolution of pregnancies and the incidence of twin pregnancies, no significant difference was observed between the two groups.

CONCLUSIONS

Because IUI and IPI allow us to obtain same results and IPI is more invasive than IUI, the latter technique can be considered the method of choice and IPI should be used when IUI is difficult to perform, as in the presence of a tight cervical canal.

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.

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).

Triggering of ovulation by a gonadotropin releasing hormone agonist in gonadotropin-stimulated cycles for prevention of ovarian hyperstimulation syndrome and multiple pregnancy

Ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies are the two main complications of ovulation induction using gonadotropins. Withholding an ovulatory dose of human chorionic gonadotropin (hCG) remains the safest option for prevention of both complications. However, this policy frustrates both patient and physician, wastes time and money due to cancelled treatment, and results in cancellation of a high proportion of cycles that would not have progressed to clinical OHSS. As gonadotropin releasing hormone analogs (GnRH-a) may elicit surges of endogenous luteinizing hormone and follicle stimulating hormone, we investigated the usefullness of a single s.c. injection of leuprolide acetate (0.5 mg) to trigger ovulation, without inducing OHSS or multiple pregnancy, in 23 consecutive gonadotropin-stimulated cycles which would otherwise have been cancelled. All patients had at least 4 mature follicles (> or = 14 mm in diameter) and plasma estradiol levels > 1000 pg/ml on the day of GnRH-a injection. No luteal support was given. Seventeen of the 23 (74%) cycles were ovulatory and four singleton pregnancies resulted, giving a pregnancy rate of 17.4% per cycle. The remaining six patients (26%) clearly had defective or short luteal phases. No patient developed OHSS. It is concluded that GnRH-a may be an acceptable substitute for hCG to salvage treatment cycles in patients thought to be at risk for OHSS or multiple pregnancy. However, further studies are necessary for optimization of this approach in order to improve ovulatory and conceptional results.