Intra-uterine insemination for male subfertility

Bensdorp A, Cohlen BJ, Heineman MJ, Vanderkerchove P

Published Online:

November 10, 2010

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. In IUI the male's sperm is prepared and placed in the uterus. Thus the sperm is close to the conception site. IUI can be performed with or without ovarian stimulation (OH). In an OH cycle women receive drugs to stimulate the ovaries to increase the number of available eggs. The main adverse effects of these drugs are multiple pregnancy and overstimulation syndrome. 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. The review found no evidence of effectiveness of either treatment. There were few trials which supplied data with our main outcome of interest; live birth rate per couple. Large, high quality properly randomised studies are needed to draw a firm conclusion.

Abstract (click to read)

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 Authors of identified articles were contacted for unpublished data.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.

This record should be cited as:

Bensdorp A, Cohlen BJ, Heineman MJ, Vanderkerchove P. Intra-uterine insemination for male subfertility. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000360. DOI: 10.1002/14651858.CD000360.pub4

Assessed as up to date:

August 23, 2007

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Subfertility > Male

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Intra-uterine insemination for male subfertility

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