-
The Cochrane Database of Systematic... Apr 2010Intrauterine insemination (IUI) should logically be performed around the moment of ovulation. Since spermatozoa and oocytes have only limited survival times correct... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Adult; Body Temperature; Chorionic Gonadotropin; Female; Gonadotropin-Releasing Hormone; Humans; Infertility; Insemination, Artificial; Luteinizing Hormone; Male; Ovulation Detection; Randomized Controlled Trials as Topic; Time Factors; Young Adult
PubMed: 20393953
DOI: 10.1002/14651858.CD006942.pub2 -
Reproductive Biomedicine Online Jan 2010The present study is based on a PubMed search and compares the clinical validity of classical semen parameters (CSP) and the sperm chromatin structure assay (SCSA) in... (Comparative Study)
Comparative Study Review
The present study is based on a PubMed search and compares the clinical validity of classical semen parameters (CSP) and the sperm chromatin structure assay (SCSA) in different clinical contexts. The PubMed database was searched using keywords on the sperm diagnostic test for pregnancy in three clinical scenarios: (i) couples attempting to conceive; (ii) couples who had been attempting to conceive for 12months without success; and (iii) couples treated with intrauterine insemination (IUI). There was a considerable heterogeneity among the studies included. For couples attempting to conceive following a SCSA that produced an abnormal result, the likelihood of male factor infertility ranged from a pre-test value of 7.5% to a post-test value of 32.1% [95% confidence interval (CI) 15.7-54.5], while after CSP with an abnormal result, the post-test probability was 17.3% (95% CI 11.8-24.5). For a pre-test prevalence of male factor infertility of 50%, the post-test probability of male factor infertility after an abnormal test is very similar for both SCSA and CSP. In couples treated with IUI, the clinical validity of SCSA is higher than that of sperm morphology alone, but not enough to introduce SCSA as a test in male infertility work-up.
Topics: Chromatin; Female; Humans; Infertility, Male; Insemination, Artificial; Male; Semen Analysis; Spermatozoa
PubMed: 20158996
DOI: 10.1016/j.rbmo.2009.10.024 -
Fertility and Sterility Mar 2009To systematically review the literature to identify randomized controlled trials, which evaluate interventions aiming to improve the probability of pregnancy in poor... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To systematically review the literature to identify randomized controlled trials, which evaluate interventions aiming to improve the probability of pregnancy in poor responders undergoing in vitro fertilization (IVF).
DESIGN
Systematic review and meta-analysis.
SETTING
University-based hospital.
INTERVENTION(S)
None.
MAIN OUTCOME MEASURE(S)
Pregnancy rate.
RESULT(S)
Twenty-two eligible randomized controlled trials were identified that evaluated in total 15 interventions to increase pregnancy rates in poor responders. Based on limited evidence, the only interventions that appear to increase the probability of pregnancy were the addition of GH to ovarian stimulation (odds ratio for live birth: 5.22, confidence interval: 95% 1.09-24.99) and the performance of embryo transfer on day 2 compared with day 3 (ongoing pregnancy rate: 27.7% vs. 16.3%, respectively; difference: +11.4, 95% confidence interval: +1.6 to +21.0).
CONCLUSION(S)
Insufficient evidence exists to recommend most of the treatments proposed to improve pregnancy rates in poor responders. Currently, there is some evidence to suggest that addition of GH, as well as performing embryo transfer on day 2 versus day 3, appear to improve the probability of pregnancy.
Topics: Administration, Cutaneous; Administration, Oral; Drug Administration Schedule; Drug Therapy, Combination; Embryo Culture Techniques; Embryo Transfer; Evidence-Based Medicine; Female; Fertility Agents, Female; Fertilization in Vitro; Growth Hormone; Humans; Insemination, Artificial; Odds Ratio; Oocyte Retrieval; Ovulation Induction; Pregnancy; Pregnancy Rate; Probability; Sperm Injections, Intracytoplasmic; Time Factors; Treatment Outcome
PubMed: 18639875
DOI: 10.1016/j.fertnstert.2007.12.077 -
Human Reproduction (Oxford, England) Oct 2008Timed intercourse (TI), which is the usual control treatment in trials of intrauterine insemination (IUI), is not a typical coital activity and could impair fertility.... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Clinical Trials as Topic; Coitus; Control Groups; Female; Humans; Insemination, Artificial; Male; Pregnancy; Pregnancy Rate; Semen
PubMed: 18617592
DOI: 10.1093/humrep/den214 -
The Cochrane Database of Systematic... Apr 2008Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples... (Review)
Review
BACKGROUND
Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples. Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus. Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates.
OBJECTIVES
To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm.
SEARCH STRATEGY
The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved.
SELECTION CRITERIA
Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available.
DATA COLLECTION AND ANALYSIS
Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed.
MAIN RESULTS
The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96).
AUTHORS' CONCLUSIONS
The findings of this systematic review support the use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.
Topics: Cervix Uteri; Cryopreservation; Female; Humans; Insemination, Artificial, Heterologous; Pregnancy; Pregnancy Rate; Randomized Controlled Trials as Topic; Semen Preservation; Uterus
PubMed: 18425862
DOI: 10.1002/14651858.CD000317.pub3 -
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 2007Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Coitus; Female; Fertilization; Humans; Infertility, Male; Insemination, Artificial; Male; Ovulation Induction
PubMed: 17943739
DOI: 10.1002/14651858.CD000360.pub4 -
The Cochrane Database of Systematic... Jul 2007Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Coitus; Female; Fertilization; Humans; Infertility, Male; Insemination, Artificial; Male; Ovulation Induction
PubMed: 17636632
DOI: 10.1002/14651858.CD000360.pub3 -
The Cochrane Database of Systematic... Jul 2007Artificial insemination with sperm is used to improve the chances of conception for various causes of infertility. Traditionally, sperm is deposited in or around the... (Review)
Review
BACKGROUND
Artificial insemination with sperm is used to improve the chances of conception for various causes of infertility. Traditionally, sperm is deposited in or around the endocervical canal (cervical insemination - CI). Some studies reported higher pregnancy rates if sperm was deposited in the uterine cavity itself (intrauterine insemination - IUI), but most were uncontrolled. However the cost and the risks (infection and anaphylaxis) of IUI may also be higher.
OBJECTIVES
The objective of this review was to assess the effects of depositing donor sperm in the uterine cavity (intrauterine insemination) compared to cervical insemination.
SEARCH STRATEGY
The Cochrane Subfertility Review Group specialised register of controlled trials was searched.
SELECTION CRITERIA
Randomised trials comparing intrauterine insemination and cervical insemination, using fresh or cryopreserved semen, with or without ovarian hyperstimulation.
DATA COLLECTION AND ANALYSIS
Trial quality assessment and data extraction were done independently by two reviewers.
MAIN RESULTS
Twelve studies were included. They comprised 697 patients undergoing 2215 treatment cycles. Ten trials used frozen semen, with three using ovarian hyperstimulation. Overall the methodological quality of the trials was low. The overall pregnancy rate per cycle in the intrauterine insemination group was 18% compared to 5% for cervical insemination. When cryopreserved donor sperm was used, the overall chance of pregnancy in spontaneous or clomiphene-corrected cycles was significantly higher with intrauterine insemination. This was irrespective of whether pregnancy rates were calculated on a per cycle (odds ratio 2.63, 95% confidence interval 1.85 to 3.73) or per patient (odds ratio 3.86, 95% confidence interval 1.81 to 8.25) basis. The greatest benefit appeared in trials with poor pregnancy rates (less than 6%) for cervical insemination. There was no difference in pregnancy rate between intrauterine and cervical insemination when fresh donor sperm was used (odds ratio 0.90, 95% confidence interval 0.36 to 2.24).
AUTHORS' CONCLUSIONS
Intrauterine insemination appears to be beneficial when cervical insemination using cryopreserved donor sperm has had low pregnancy rates. This applies to spontaneous, clomiphene corrected and gonadotrophin stimulated cycles. However it may offer little benefit where high pregnancy rates have been achieved with cervical insemination. There appears to be no additional benefit from intrauterine insemination when fresh sperm is used for donor insemination.
Topics: Cervix Uteri; Female; Humans; Insemination, Artificial; Pregnancy; Pregnancy Rate; Uterus
PubMed: 17636628
DOI: 10.1002/14651858.CD000317.pub2 -
The Cochrane Database of Systematic... Apr 2007Intrauterine insemination (IUI) combined with ovarian hyperstimulation (OH) has been demonstrated to be an effective form of treatment for subfertile couples. Several... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intrauterine insemination (IUI) combined with ovarian hyperstimulation (OH) has been demonstrated to be an effective form of treatment for subfertile couples. Several ovarian stimulation protocols combined with IUI have been proposed, but it is still not clear which stimulation protocol and which dose is the most cost-effective.
OBJECTIVES
To evaluate ovarian stimulation protocols for intrauterine insemination for all indications.
SEARCH STRATEGY
We searched for all publications which described randomised controlled trials comparing different ovarian stimulation protocols followed by IUI. We searched the Menstrual Disorders and Subfertility Group's Central register of Controlled Trials (CENTRAL). We searched the electronic databases of MEDLINE (January 1966 to present) and EMBASE (1980 to present).
SELECTION CRITERIA
Randomised controlled trials only were considered for inclusion in this review. Trials comparing different ovarian stimulation protocols combined with IUI were selected and reviewed in detail.
DATA COLLECTION AND ANALYSIS
Two independent review authors independently assess trial quality and extracted data.
MAIN RESULTS
Forty three trials involving 3957 women were included. There were 11 comparisons in this review. Pregnancy rates are reported here since results of live birth rates were lacking. Seven studies (n = 556) were pooled comparing gonadotrophins with anti-oestrogens showing significant higher pregnancy rates with gonadotrophins (OR 1.8, 95% CI 1.2 to 2.7). Five studies (n = 313) compared anti-oestrogens with aromatase inhibitors reporting no significant difference (OR 1.2 95% CI 0.64 to 2.1). The same could be concluded comparing different types of gonadotrophins (9 studies included, n = 576). Four studies (n = 391) reported the effect of adding a GnRH agonist which did not improve pregnancy rates (OR 0.98 95% CI 0.6 to 1.6), although it resulted in significant higher multiple pregnancy rates (OR 2.9 95% CI 1.0 to 8). Data of three studies (n = 299) showed no convincing evidence of adding a GnRH antagonist to gonadotrophins (OR 1.5 95% CI 0.83 to 2.8). The results of two studies (n = 297) reported no evidence of benefit in doubling the dose of gonadotrophins (OR 1.2 95% 0.67 to 1.9) although the multiple pregnancy rates and OHSS rates were increased. For the remaining five comparisons only one or none studies were included.
AUTHORS' CONCLUSIONS
Robust evidence is lacking but based on the available results gonadotrophins might be the most effective drugs when IUI is combined with ovarian hyperstimulation. When gonadotrophins are applied it might be done on a daily basis. When gonadotrophins are used for ovarian stimulation low dose protocols are advised since pregnancy rates do not differ from pregnancy rates which result from high dose regimen, whereas the chances to encounter negative effects from ovarian stimulation such as multiples and OHSS are limited with low dose gonadotrophins. Further research is needed for each comparison made.
Topics: Estrogen Antagonists; Female; Gonadotropin-Releasing Hormone; Gonadotropins; Humans; Infertility; Insemination, Artificial; Ovulation Induction; Randomized Controlled Trials as Topic
PubMed: 17443584
DOI: 10.1002/14651858.CD005356.pub2