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The Cochrane Database of Systematic... Sep 2012Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in... (Meta-Analysis)
Meta-Analysis Review
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 Authors of identified studies were contacted for missing or unpublished data.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.
Topics: Coitus; Female; Fertile Period; Humans; Infertility; Insemination, Artificial; Live Birth; Male; Ovulation Induction; Pregnancy; Pregnancy Rate; Pregnancy, Multiple; Randomized Controlled Trials as Topic; Time Factors
PubMed: 22972053
DOI: 10.1002/14651858.CD001838.pub4 -
Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities.The Cochrane Database of Systematic... Jan 2013Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility.
OBJECTIVES
To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).
SEARCH METHODS
We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (6 August 2012), the Cochrane Central Register of Controlled Trials (T he Cochrane Library 2012, Issue 7), MEDLINE (1950 to October 2012), EMBASE (1974 to October 2012), CINAHL (from inception to October 2012) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2008 to October 2012) and we contacted experts in the field.
SELECTION CRITERIA
Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.
MAIN RESULTS
Two studies met the inclusion criteria and neither reported the primary outcomes of live birth and complications from the procedure. In women with otherwise unexplained subfertility and submucous fibroids, there is no evidence of benefit with hysteroscopic myomectomy compared to regular fertility-oriented intercourse during 12 months for clinical pregnancy (odds ratio (OR) 2.4, 95% confidence interval (CI) 0.97 to 6.2, P = 0.06, 94 women) and miscarriage (OR 1.5, 95% CI 0.47 to 5.0, P = 0.47, 94 women) (very low-quality evidence). The hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy (experimental event rate (EER) 63%) compared to diagnostic hysteroscopy and polyp biopsy only (control event rate (CER) 28%) (OR 4.4, 95% CI 2.5 to 8.0, P < 0.00001, 204 women, high-quality evidence).
AUTHORS' CONCLUSIONS
Hysteroscopic myomectomy might increase the odds of clinical pregnancy in women with unexplained subfertility and submucous fibroids, but the evidence is at present not conclusive. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI might increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.
Topics: Coitus; Endometrium; Female; Fertilization in Vitro; Humans; Hysteroscopy; Infertility; Insemination, Artificial; Leiomyoma; Polyps; Pregnancy; Randomized Controlled Trials as Topic; Tissue Adhesions; Uterine Diseases; Uterus
PubMed: 23440838
DOI: 10.1002/14651858.CD009461.pub2 -
Fertility and Sterility Mar 2016To evaluate the effectiveness of semen washing in human immunodeficiency virus (HIV)-discordant couples in which the male partner is infected. (Meta-Analysis)
Meta-Analysis Review
Effectiveness of semen washing to prevent human immunodeficiency virus (HIV) transmission and assist pregnancy in HIV-discordant couples: a systematic review and meta-analysis.
OBJECTIVE
To evaluate the effectiveness of semen washing in human immunodeficiency virus (HIV)-discordant couples in which the male partner is infected.
DESIGN
Systematic review and meta-analysis.
SETTING
Not applicable.
PATIENT(S)
Forty single-arm open-label studies among HIV-discordant couples that underwent intrauterine insemination (IUI) or in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) using washed semen.
INTERVENTION(S)
Semen washing followed by IUI, IVF, or IVF/ICSI.
PRIMARY OUTCOME
HIV transmission to HIV-uninfected women; secondary outcomes: HIV transmission to newborns and proportion of couples achieving a clinical pregnancy.
RESULT(S)
No HIV transmission occurred in 11,585 cycles of assisted reproduction with the use of washed semen among 3,994 women. Among the subset of HIV-infected men without plasma viral suppression at the time of semen washing, no HIV seroconversions occurred among 1,023 women after 2,863 cycles of assisted reproduction with the use of washed semen. Studies that measured HIV transmission to infants reported no cases of vertical transmission. Overall, 56.3% of couples (2,357/4,184) achieved a clinical pregnancy with the use of washed semen.
CONCLUSION(S)
Semen washing appears to significantly reduce the risk of transmission in HIV-discordant couples desiring children, regardless of viral suppression in the male partner. There are no randomized controlled studies or studies from low-income countries, especially those with a large burden of HIV. Continued development of lower-cost semen washing and assisted reproduction technologies is needed. Integration of semen washing into HIV prevention interventions could help to further reduce the spread of HIV.
Topics: Adult; Female; Fertilization in Vitro; HIV; HIV Infections; HIV Seronegativity; HIV Seropositivity; Humans; Infectious Disease Transmission, Vertical; Insemination, Artificial; Male; Middle Aged; Pregnancy; Pregnancy Rate; Risk Factors; Sperm Injections, Intracytoplasmic; Sperm Retrieval; Spermatozoa; Treatment Outcome
PubMed: 26688556
DOI: 10.1016/j.fertnstert.2015.11.028 -
The Cochrane Database of Systematic... Nov 2010Intrauterine insemination (IUI) is a recommended treatment for unexplained subfertility. The treatment involves the direct delivery of spermatozoa into the uterus using... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intrauterine insemination (IUI) is a recommended treatment for unexplained subfertility. The treatment involves the direct delivery of spermatozoa into the uterus using a catheter. Many factors influence the success of IUI treatments including the type of catheter used.
OBJECTIVES
To compare pregnancy-related outcomes from women undergoing intrauterine insemination cycles performed with either soft or firm catheters in subfertile women.
SEARCH STRATEGY
We searched the following databases (inception to July 2010) with no language restrictions: Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS and OpenSigle. We also searched the conference abstracts in the ISI Web of Knowledge and Google, and conference abstracts and citation lists of relevant publications, reviews and included studies.
SELECTION CRITERIA
We included only truly randomised controlled studies of women who underwent IUI using either soft or firm catheter types and reporting data on rates of live birth, clinical pregnancy, multiple pregnancy, miscarriage, ease of introduction of the catheter, occurrence of trauma, or woman's discomfort.
DATA COLLECTION AND ANALYSIS
Two review authors screened the titles and abstracts of 78 potentially eligible studies and excluded 66 of these. We critically appraised the full texts of twelve studies and excluded three studies. Nine publications of six studies were remaining. We extracted data from the six remaining studies and there were no disagreements. We assessed risk of bias and pooled dichotomous data and presented the Peto odds ratios (OR) with 95% confidence intervals (CI).
MAIN RESULTS
There was no evidence of a significant effect difference regarding the choice of catheter type for any of the outcomes. Three studies reported live birth rates (OR 0.94, 95% CI 0.65 to 1.35) with a translated OR percentages (1.3, 95% CI 0.56 to 3.1) while six studies reported clinical pregnancy rates (OR 1.0, 95% CI 0.73 to 1.35 ). Two studies were pooled for the analysis of miscarriages (OR 1.25, 95% CI 0.49 to 3.22). Results of other adverse outcomes were reported per cycle and were therefore not pooled.
AUTHORS' CONCLUSIONS
On the basis of the evidence available in this review, no specific conclusion can be made regarding the superiority of one catheter class over another. Further adequately powered studies reporting on clinical outcomes (e.g. live birth rate) are required. Additional outcomes such as miscarriage rates and measures of discomfort need to be reported.
Topics: Catheters; Equipment Design; Female; Humans; Infertility; Insemination, Artificial; Pregnancy; Pregnancy Outcome
PubMed: 21069687
DOI: 10.1002/14651858.CD006225.pub2 -
The Cochrane Database of Systematic... Oct 2007Semen preparation techniques for assisted reproduction, including intrauterine insemination (IUI), were developed to separate the motile morphological normal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Semen preparation techniques for assisted reproduction, including intrauterine insemination (IUI), were developed to separate the motile morphological normal spermatozoa. Leucocytes, bacteria and dead spermatozoa produce oxygen radicals that negatively influence the ability to fertilize the egg. The yield of as many motile, morphologically normal spermatozoa as possible might influence treatment choices and therefore outcomes.
OBJECTIVES
To compare the effectiveness of gradient, swim-up, or wash and centrifugation semen preparation techniques on clinical outcome in subfertile couples undergoing intrauterine insemination (IUI).
SEARCH STRATEGY
We searched the Menstrual Disorders and Subfertility Group Trials Register (13 January 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to January 2007 ), EMBASE (1980 to January 2007), Science Direct Database (1966 to January 2007), National Research Register (2000 to 2007), Biological Abstracts (2000 to January 2007), CINAHL (1982 to October 2006) and reference lists of relevant articles. We also contacted experts and authors in the field.
SELECTION CRITERIA
Parallel randomized controlled trials (RCTs) comparing the efficacy of semen preparation techniques used for subfertile couples undergoing IUI in terms of clinical outcome were included.
DATA COLLECTION AND ANALYSIS
Two reviewer authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.
MAIN RESULTS
Five RCTs, including 262 couples in total, were included in the meta-analysis (Dodson 1998; Grigoriou 2005; Posada 2005; Soliman 2005; Xu 2000). Xu compared the three techniques; Soliman compared a gradient technique versus a wash technique; Dodson and Posada compared a gradient technique versus a swim-up technique; whereas Grigoriou compared swim-up versus a wash technique. No trials reported the primary outcome of live birth. There was no evidence of a difference between pregnancy rates (PR) for swim-up versus a gradient or wash and centrifugation technique (Peto OR 1.57, 95% CI 0.74 to 3.32; Peto OR 0.41, 95% CI 0.15 to 1.10, respectively); nor in the two studies comparing a gradient technique versus wash and centrifugation (Peto OR 1.76, 95% CI 0.57 to 5.44). There was no evidence of a difference in the miscarriage rate (MR) in two studies comparing swim-up versus a gradient technique (Peto OR 0.13, 95% CI 0.01 to 1.33).
AUTHORS' CONCLUSIONS
There is insufficient evidence to recommend any specific preparation technique. Large high quality randomised controlled trials, comparing the effectiveness of a gradient and/ or a swim-up and/ or wash and centrifugation technique on clinical outcome are lacking. Further randomised trials are warranted.
Topics: Centrifugation, Density Gradient; Humans; Insemination, Artificial; Male; Randomized Controlled Trials as Topic; Semen; Specimen Handling; Sperm Count; Sperm Motility; Spermatozoa
PubMed: 17943816
DOI: 10.1002/14651858.CD004507.pub3 -
The Cochrane Database of Systematic... Oct 2006Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Female; Humans; Infertility; Insemination, Artificial; Male; Pregnancy; Pregnancy Rate; Randomized Controlled Trials as Topic
PubMed: 17054143
DOI: 10.1002/14651858.CD001838.pub3 -
The Cochrane Database of Systematic... Feb 2016Intra-uterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) are frequently used fertility treatments for couples with male... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Birth Rate; Coitus; Female; Fertilization; Humans; Infertility, Male; Insemination, Artificial; Male; Ovulation Induction; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 26915339
DOI: 10.1002/14651858.CD000360.pub5 -
Human Reproduction Update 2013BACKGROUND In recent years, changes in attitudes towards (non-)disclosure of donor conception to offspring and/or others have been observed. Studies have started to... (Review)
Review
BACKGROUND In recent years, changes in attitudes towards (non-)disclosure of donor conception to offspring and/or others have been observed. Studies have started to identify possible factors that contribute to these changes that are relevant for clinics, counsellors and policy-makers in their approach to the disclosure process. The aim of this systematic review was to integrate the existing knowledge on factors that influence the disclosure decision-making process of donor conception to offspring and/or others in heterosexual couples, and to discuss future trends and concerns. METHODS A bibliographic search of English, French, German and Dutch language publications of five computerized databases was undertaken from January 1980 to March 2012. A Cochrane Database systematic review approach was applied. RESULTS A total of 43 studies met the inclusion criteria, and these represented 36 study populations. The review shows that the parents' disclosure decision-making process is influenced by a myriad of intrapersonal, interpersonal, social and family life cycle features. These influences were not necessarily independent but rather were interwoven and overlapping. Theoretical frameworks have not yet been used to explain how the different factors influenced disclosure. Methodological limitations of the original publications (lack of information, several factors included in one study, descriptive character of studies) and this review (multiple factors that may interact) which hindered integration of the findings are outlined. CONCLUSIONS Intrapersonal, interpersonal, social and family life cycle factors influence the parents' disclosure decision-making process. The review has demonstrated the need for the development of a theoretical model to enable integration of the identified influencing factors. Further research is needed on the role of stigma, confrontation efficacy, extended family, donor siblings' characteristics, cross-border treatment, culture, gender and socio-educational factors.
Topics: Attitude; Decision Making; Disclosure; Humans; Insemination, Artificial, Heterologous; Male; Oocyte Donation; Oocytes; Parents; Spermatozoa; Tissue Donors
PubMed: 23814103
DOI: 10.1093/humupd/dmt018 -
The Cochrane Database of Systematic... Jan 2018The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI). (Comparative Study)
Comparative Study Review
BACKGROUND
The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI).
OBJECTIVES
To compare the effectiveness and safety of intrauterine insemination (IUI) and intracervical insemination (ICI) in women who start donor sperm treatment.
SEARCH METHODS
We searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL in October 2016, checked references of relevant studies, and contacted study authors and experts in the field to identify additional studies. We searched PubMed, Google Scholar, the Grey literature, and five trials registers on 15 December 2017.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) reporting on IUI versus ICI in natural cycles or with ovarian stimulation, and RCTs comparing different cointerventions in IUI and ICI. We included cross-over studies if pre-cross-over data were available.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures recommended by Cochrane. We collected data on primary outcomes of live birth and multiple pregnancy rates, and on secondary outcomes of clinical pregnancy, miscarriage, and cancellation rates.
MAIN RESULTS
We included six RCTs (708 women analysed) on ICI and IUI in donor sperm treatment. Two studies compared IUI and ICI in natural cycles, two studies compared IUI and ICI in gonadotrophin-stimulated cycles, and two studies compared timing of IUI and ICI. There was very low-quality evidence; the main limitations were risk of bias due to poor reporting of study methods, and serious imprecision.IUI versus ICI in natural cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in natural cycles (odds ratio (OR) 3.24, 95% confidence interval (CI) 0.12 to 87.13; 1 RCT, 26 women; very low-quality evidence). There was only one live birth in this study (in the IUI group). IUI resulted in higher clinical pregnancy rates (OR 6.18, 95% CI 1.91 to 20.03; 2 RCTs, 76 women; I² = 48%; very low-quality evidence).No multiple pregnancies or miscarriages occurred in this study.IUI versus ICI in gonadotrophin-stimulated cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in gonadotrophin-stimulated cycles (OR 2.55, 95% CI 0.72 to 8.96; 1 RCT, 43 women; very low-quality evidence). This suggested that if the chance of a live birth following ICI in gonadotrophin-stimulated cycles was assumed to be 30%, the chance following IUI in gonadotrophin-stimulated cycles would be between 24% and 80%. IUI may result in higher clinical pregnancy rates than ICI (OR 2.83, 95% CI 1.38 to 5.78; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). IUI may be associated with higher multiple pregnancy rates than ICI (OR 2.77, 95% CI 1.00 to 7.69; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). This suggested that if the risk of multiple pregnancy following ICI in gonadotrophin-stimulated cycles was assumed to be 10%, the risk following IUI would be between 10% and 46%.We found insufficient evidence to determine whether there was any clear difference between the groups in miscarriage rates in gonadotrophin-stimulated cycles (OR 1.97, 95% CI 0.43 to 9.04; 2 RCTs, overall 67 pregnancies; I² = 50%; very low-quality evidence).Timing of IUI and ICIWe found no studies that reported on live birth rates.We found a higher clinical pregnancy rate when IUI was timed one day after a rise in blood levels of luteinising hormone (LH) compared to IUI two days after a rise in blood levels of LH (OR 2.00, 95% CI 1.14 to 3.53; 1 RCT, 351 women; low-quality evidence). We found insufficient evidence to determine whether there was any clear difference in clinical pregnancy rates between ICI timed after a rise in urinary levels of LH versus a rise in basal temperature plus cervical mucus scores (OR 1.31, 95% CI 0.42 to 4.11; 1 RCT, 56 women; very low-quality evidence).Neither of these studies reported multiple pregnancy or miscarriage rates as outcomes.
AUTHORS' CONCLUSIONS
There was insufficient evidence to determine whether there was a clear difference in live birth rates between IUI and ICI in natural or gonadotrophin-stimulated cycles in women who started with donor sperm treatment. There was insufficient evidence available for the effect of timing of IUI or ICI on live birth rates. Very low-quality data suggested that in gonadotrophin-stimulated cycles, ICI may be associated with a higher clinical pregnancy rate than IUI, but also with a higher risk of multiple pregnancy rate. We concluded that the current evidence was too limited to choose between IUI or ICI, in natural cycles or with ovarian stimulation, in donor sperm treatment.
Topics: Body Temperature; Cervix Mucus; Female; Gonadotropins; Humans; Insemination, Artificial, Heterologous; Live Birth; Luteinizing Hormone; Menstrual Cycle; Pregnancy; Pregnancy Rate; Pregnancy, Multiple; Randomized Controlled Trials as Topic
PubMed: 29368795
DOI: 10.1002/14651858.CD000317.pub4 -
The Cochrane Database of Systematic... Nov 2015One-third of subfertile couples have no identifiable cause for their inability to conceive. In vitro fertilisation (IVF) is a widely accepted treatment for this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
One-third of subfertile couples have no identifiable cause for their inability to conceive. In vitro fertilisation (IVF) is a widely accepted treatment for this condition; however, this treatment is invasive and expensive and is associated with risks.
OBJECTIVES
To evaluate the effectiveness and safety of IVF compared with expectant management, unstimulated intrauterine insemination (IUI) or intrauterine insemination along with ovarian stimulation with gonadotropins (IUI + gonadotropins) or clomiphene (IUI + CC) or letrozole (IUI + letrozole) in improving pregnancy outcomes.
SEARCH METHODS
This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, first quarter), MEDLINE (1946 to May 2015), EMBASE (1985 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (May 2015) and reference lists of articles. We searched the following trial registries: clinicaltrials.gov (http://www.clinicaltrials.gov) and the World Health Organization International Trials Registry Platform search portal (http://www.who.int/trialsearch/Default.aspx). We searched the Web of Science (http://wokinfo.com/) as another source of trials and conference abstracts, OpenGrey (http://www.opengrey.eu/) for unpublished literature from Europe and the Latin American Caribbean Health Sciences Literature (LILACS) database (http://regional.bvsalud.org/php/index.php?lang=en). Moreover, we handsearched relevant conference proceedings and contacted study authors to ask about additional publications.Two review authors independently assessed trial eligibility, extracted data and assessed risk of bias. The primary review outcome was cumulative live birth rate. Multiple pregnancy and other adverse effects were secondary outcomes. We combined data to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity by using the I(2) statistic. We assessed the overall quality of evidence for the main comparisons using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) in which the effectiveness of IVF in couples with unexplained subfertility was compared with that of other treatments, including expectant management, unstimulated IUI and stimulated IUI using gonadotropins or clomiphene or letrozole.Live birth rate (LBR) per woman was the primary outcome.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the eligibility and quality of trials and evaluated the quality of the evidence by using GRADE criteria.
MAIN RESULTS
IVF versus expectant management (two RCTs):Live birth rate per woman was higher with IVF than with expectant management (odds ratio (OR) 22.00, 95% confidence interval (CI) 2.56 to 189.37, one RCT, 51 women, very low quality evidence). Multiple pregnancy rates (MPRs), ovarian hyperstimulation syndrome (OHSS) and miscarriage were not reported. IVF versus unstimulated IUI (two RCTs):Live birth rate was higher with IVF than with unstimulated IUI (OR 2.47, 95% CI 1.19 to 5.12, two RCTs, 156 women, I(2) = 60%, low quality evidence). There was no evidence of a difference between the groups in multiple pregnancy rates (OR 1.03, 95% CI 0.04 to 27.29, one RCT, 43 women, very low quality evidence) IVF versus IUI + ovarian stimulation with gonadotropins (three RCTs) or clomiphene (one RCT) or letrozole (no RCTs):Data from these trials could not be pooled because of high statistical heterogeneity (I(2) = 93.3%). Heterogeneity was eliminated when studies were stratified by pretreatment status.In trials comparing IVF versus IUI + gonadotropins among treatment-naive women, there was no conclusive evidence of a difference between the groups in live birth rates (OR 1.27, 95% CI 0.94 to 1.73, four RCTs, 745 women, I(2) = 8.0%, moderate-quality evidence). In women pretreated with IUI + clomiphene, a higher live birth rate was reported among those who underwent IVF than those given IUI + gonadotropins (OR 3.90, 95% CI 2.32 to 6.57, one RCT, 280 women, moderate-quality evidence).There was no conclusive evidence of a difference in live birth rates between IVF and IUI + CC in treatment-naive women (OR 2.51, 95% CI 0.96 to 6.55, one RCT, 103 women, low quality evidence).In treatment-naive women, there was no evidence of a difference in rates of multiple pregnancy between women who underwent IVF and those who received IUI + gonadotropins (OR 0.79, 95% CI 0.45 to 1.39, four RCTs, 745 women, I(2) = 0%, moderate quality evidence). There was no evidence of a difference in MPRs between women who underwent IVF compared with those given IUI + CC (OR 1.02, 95% CI 0.20 to 5.31, one RCT, 103 women, low-quality evidence).There was no evidence of a difference in ovarian hyperstimulation syndrome rate between treatment-naive women who underwent IVF and those given IUI + gonadotropins (OR 1.23, 95% CI 0.36 to 4.14, two RCTs, 221 women, low quality evidence). There was no evidence of a difference in OHSS rates between groups receiving IVF versus those receiving IUI + CC (OR 1.02, 95% CI 0.20 to 5.31, one RCT, 103 women, low-quality evidence).In treatment naive women, there was no evidence of a difference in miscarriage rates between IVF and IUI + CC (OR 1.16, 95% CI 0.44 to 3.02, one RCT, 103 women, low-quality evidence), nor between women treated with IVF versus those receiving IUI+ gonadotropins (OR 1.16, 95% CI 0.44 to 3.02, one RCT, 103 women).No studies compared IVF with IUI + letrozole.The quality of the evidence ranged from very low to moderate. The main limitation was serious imprecision resulting from small study numbers and low event rates.
AUTHORS' CONCLUSIONS
IVF may be associated with higher live birth rates than expectant management, but there is insufficient evidence to draw firm conclusions. IVF may also be associated with higher live birth rates than unstimulated IUI. In women pretreated with clomiphene + IUI, IVF appears to be associated with higher birth rates than IUI + gonadotropins. However in women who are treatment-naive there is no conclusive evidence of a difference in live birth rates between IVF and IUI + gonadotropins or between IVF and IUI + clomiphene. Adverse events associated with these interventions could not be adequately assessed owing to lack of evidence.
Topics: Clomiphene; Female; Fertility Agents, Female; Fertilization in Vitro; Gamete Intrafallopian Transfer; Humans; Infertility, Female; Insemination, Artificial; Live Birth; Ovulation Induction; Randomized Controlled Trials as Topic; Watchful Waiting
PubMed: 26583517
DOI: 10.1002/14651858.CD003357.pub4