First line fertility treatment strategies regarding IUI and IVF require clinical evidence

Disrupting the biological clock: Fertility benefits, egg freezing and proactive fertility management

In the last decade, the in-vitro fertilization (IVF) sector has witnessed a shift from so-called 'reactive IVF' to a new model of proactive fertility care. Whereas IVF was traditionally developed to treat people who found they were unable to conceive, the indication for IVF has broadened significantly to include a much wider group of potential patients through a new focus on proactive treatment of future (in)fertilities. This shift combines a number of new trends pertaining to preservation, prediction, private equity and platformization, all of which have gained influence in contemporary assisted reproduction. This article focuses on the emergence of company-sponsored fertility benefits, which combines each of these trends. Whereas fertility benefits - especially egg freezing insurance - have primarily been discussed in terms of women's empowerment or disenfranchisement, this article instead calls attention to the discursive, clinical and infrastructural shifts in contemporary assisted reproduction that have emerged with the rising popularity of these benefits. The analysis addresses these underdiscussed aspects of fertility benefits by focusing on the dynamics of demand; the shifts in the rationalization of intensified treatment pathways in the face of new reimbursement practices; and the online, platform-based infrastructures that are built to provide these treatments. In doing so, it analyses how this remaking of fertility towards an ethos of proactive fertility management reflects broader capitalist tailwinds.

Comparison of RNA content from hydrophobic interaction chromatography-isolated seminal plasma exosomes from intrauterine insemination (IUI) pregnancies

Male factors account for roughly half of infertility cases, with most male infertility diagnosed as idiopathic. Researchers predicting intrauterine insemination success rates have identified multiple prognostic factors, including semen parameters and seminal fluid composition. Seminal plasma contains extracellular exosomes, which contain RNAs and proteins involved in spermatogenesis. The contents of seminal plasma exosomes may be an indicator of overall sperm quality or fertility potential; therefore, analysis of exosomes may provide a measure for sperm viability and fertilization potential. In our study, exosomes were isolated and purified from seminal plasma obtained from IUI treatments with known pregnancy outcomes. We used a unique method to isolate the exosomes which made use of the hydrophobic interaction chromatography method. RNASeq was performed on RNAs from the purified exosomes. This analysis revealed holistic trends, including increased expression associated with RNA originating from chromosomes 1, 10, 12, 16 and 21. Overall, total RNA was significantly decreased and rRNA was significantly increased in successful IUI attempts. Furthermore, we found specific mRNAs and lincRNAs associated with positive versus negative pregnancy outcomes. Our study isolated and purified seminal plasma exosomes without ultracentrifugation, and it provides further evidence for differences in seminal plasma exosome molecular contents associated with pregnancy status.

Dispensing of clomiphene citrate to treat infertility: medication supplied and population prevalence of assisted pregnancies and multiple births

OBJECTIVE

To determine the proportion of pregnancies resulting in birth that were conceived with the use of clomiphene citrate (CC) and the frequency of multiple pregnancy.

DESIGN

Whole-of-population cohort study, constructed through data linkage. Comprehensive Australian Government records of dispensed medications were linked to state Perinatal Registry records for all births of at least 20 weeks' gestation.

SETTING

The state of South Australia.

PATIENT(S)

Women who maintained pregnancy for at least 20 weeks and gave birth between July 2003 and December 2015, a total of 150,713 women with 241,561 pregnancies.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy occurring in proximity to CC, defined as dispensing from 90 days before to the end of a conception window derived from newborn date of birth and gestational age.

RESULT(S)

Linkage to dispensed prescription records was achieved for 97.9% of women. Women who conceived with CC tended to be older and socioeconomically advantaged and more likely than other women to have a history of miscarriage. Ongoing pregnancies associated with CC comprised 1.6% of the total; 5.7% were multiple births (mostly twins, 94.6%) compared with 1.5% in the remainder (98.5% twins).

CONCLUSION(S)

In South Australia, 1.6% of pregnancies (1 in 60) of at least 20 weeks' gestation were conceived proximal to CC dispensing. Of these, 5.7% were multiple pregnancies. This takes the proportion of women who achieved an ongoing pregnancy with medical assistance from 4.4%, based on reports from assisted reproductive technology clinics, to 6% in total.

CNFE-SE: a novel approach combining complex network-based feature engineering and stacked ensemble to predict the success of intrauterine insemination and ranking the features

Background

Intrauterine Insemination (IUI) outcome prediction is a challenging issue which the assisted reproductive technology (ART) practitioners are dealing with. Predicting the success or failure of IUI based on the couples' features can assist the physicians to make the appropriate decision for suggesting IUI to the couples or not and/or continuing the treatment or not for them. Many previous studies have been focused on predicting the in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) outcome using machine learning algorithms. But, to the best of our knowledge, a few studies have been focused on predicting the outcome of IUI. The main aim of this study is to propose an automatic classification and feature scoring method to predict intrauterine insemination (IUI) outcome and ranking the most significant features.

Methods

For this purpose, a novel approach combining complex network-based feature engineering and stacked ensemble (CNFE-SE) is proposed. Three complex networks are extracted considering the patients' data similarities. The feature engineering step is performed on the complex networks. The original feature set and/or the features engineered are fed to the proposed stacked ensemble to classify and predict IUI outcome for couples per IUI treatment cycle. Our study is a retrospective study of a 5-year couples' data undergoing IUI. Data is collected from Reproductive Biomedicine Research Center, Royan Institute describing 11,255 IUI treatment cycles for 8,360 couples. Our dataset includes the couples' demographic characteristics, historical data about the patients' diseases, the clinical diagnosis, the treatment plans and the prescribed drugs during the cycles, semen quality, laboratory tests and the clinical pregnancy outcome.

Results

Experimental results show that the proposed method outperforms the compared methods with Area under receiver operating characteristics curve (AUC) of 0.84 ± 0.01, sensitivity of 0.79 ± 0.01, specificity of 0.91 ± 0.01, and accuracy of 0.85 ± 0.01 for the prediction of IUI outcome.

Conclusions

The most important predictors for predicting IUI outcome are semen parameters (sperm motility and concentration) as well as female body mass index (BMI).

Prewash and postwash total progressively motile sperm counts have poor predictive value for clinical pregnancy after intrauterine insemination

OBJECTIVE

To evaluate the predictive value of the prewash and postwash total progressively motile sperm counts (TPMSC) on clinical pregnancy after intrauterine insemination (IUI) .

METHODS

A review of medical records of women undergoing 2064 IUI cycles in a university hospital between April 2010 and October 2018.

RESULTS

No pregnancies were seen when the prewash TPMSC was less than 9 million or the postwash TPMSC was less than 2 million. There was no correlation between TPMSC and clinical pregnancies. Further analysis was made in pregnancies after prewash TPMSC of 3-10 million and more than 10 million, and after postwash TPMSC of 10-100 million and more than 100 million. No correlation was found between TPMSC and clinical pregnancy in different strata of female age, infertility duration, type of infertility, type of IUI treatment, and the number of treatment cycles. A negative relationship was found for unstimulated IUI treatment and the number of treatment cycles. The prewash and postwash TPMSC showed no predictive value.

CONCLUSION

Prewash and postwash TPMSC have poor predictive value for clinical pregnancy in IUI. Cycles with a prewash TPMSC of 10-100 million or postwash TPMSC of 3-10 million could achieve acceptable pregnancy rates with IUI.

Sterility, an Overlooked Health Condition

Clinically, infertility is defined as the inability to conceive after a certain period. In contrast, sterility is defined as the inability to produce a biological child; however, this is not a practical definition that can be applied in a clinical setting to a patient’s diagnosis. Unlike infertility, sterility is rarely discussed in biomedical and clinical literature and is often used synonymously with infertility. Infertility affects about 10% of couples globally, but the prevalence of sterility remains unknown. We divide sterility into three subtypes natural, clinical, and hardship. To estimate sterility prevalence, we analyzed primary literature and meta-analysis papers on the rates of live births and pregnancies throughout several treatments of infertile couples (e.g., untreated patients, in vitro fertilization-treated, and patients administered other treatments). This analysis indicates that all treatments fail in delivering a biological child to most couples, suggesting that most infertile couples may fail to conceive. More comprehensive primary studies are needed to provide a precise estimate of sterility. Furthermore, research is needed to study the causes of sterility, as well as develop methods for diagnosis and treatment that are financially affordable and emotionally tolerable. Altogether, sterility is an under-discussed condition that is more common than expected, as many infertile couples are unable to conceive and are, in effect, sterile.

Cumulative live birth rates following insemination with donor spermatozoa in single women, same-sex couples and heterosexual patients

RESEARCH QUESTION

What is the cumulative live birth rate (LBR) following donor intrauterine insemination (IUI-D) treatment in a large, retrospective, single-centre cohort of single women, same-sex couples and heterosexual patients?

DESIGN

Outcomes from 8922 treatments performed in 3333 consecutive women (45% single, 43% from same-sex and 12% from heterosexual couples) were analysed in a 13-year retrospective study from a private, HFEA-regulated UK centre between January 2004 and December 2016.

RESULTS

A total of 795 live births resulted in an overall delivery rate of 8.9% per cycle, including 24 (3%) twins. Age-specific crude and expected cumulative LBR calculated in four age groups (<35, 35-37, 38-39 and 40-42 years) were 29, 23, 21, 12% and 66, 49, 54, 28%, respectively. A plateau was reached after six cycles, beyond which there were few additional live births. There was no significant difference in cumulative LBR between single women and same-sex couples. In a multivariate analysis, female age (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.90-0.93; P < 0.0001), previous live birth following IUI-D (aOR 2.15; 95% CI 1.69-2.73; P < 0.0001) and mild stimulation (aOR 1.27; 95% CI 1.09-1.48; P = 0.02) had a significant effect on outcome, but relationship status or cycle rank did not.

CONCLUSIONS

These results indicate there is little benefit performing more than six cycles of IUI-D in all women up to 40 years old, including those from same-sex relationships, while only three attempts seem reasonable in those aged 40-42 years. These results do not reflect current clinical guidelines in the UK. The authors found that consecutive IUI cycles, especially with mild stimulation, were an efficient treatment in all indications.

Predicting the chances of having a baby with or without treatment at different time points in couples with unexplained subfertility

STUDY QUESTION

Can we develop a prediction model that can estimate the chances of conception leading to live birth with and without treatment at different points in time in couples with unexplained subfertility?

SUMMARY ANSWER

Yes, a dynamic model was developed that predicted the probability of conceiving under expectant management and following active treatments (in vitro fertilisation (IVF), intrauterine insemination with ovarian stimulation (IUI + SO), clomiphene) at different points in time since diagnosis.

WHAT IS KNOWN ALREADY

Couples with no identified cause for their subfertility continue to have a realistic chance of conceiving naturally, which makes it difficult for clinicians to decide when to intervene. Previous fertility prediction models have attempted to address this by separately estimating either the chances of natural conception or the chances of conception following certain treatments. These models only make predictions at a single point in time and are therefore inadequate for informing continued decision-making at subsequent consultations.

STUDY DESIGN, SIZE, DURATION

A population-based study of 1316 couples with unexplained subfertility attending a regional clinic between 1998 and 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A dynamic prediction model was developed that estimates the chances of conception within 6 months from the point when a diagnosis of unexplained subfertility was made. These predictions were recomputed each month to provide a dynamic assessment of the individualised chances of conception while taking account of treatment status in each month. Conception must have led to live birth and treatments included clomiphene, IUI + SO, and IVF. Predictions for natural conception were externally validated using a prospective cohort from The Netherlands.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 554 (42%) couples started fertility treatment within 2 years of their first fertility consultation. The natural conception leading to live birth rate was 0.24 natural conceptions per couple per year. Active treatment had a higher chance of conception compared to those who remained under expectant management. This association ranged from weak with clomiphene to strong with IVF [clomiphene, hazard ratio (HR) = 1.42 (95% confidence interval, 1.05 to 1.91); IUI + SO, HR = 2.90 (2.06 to 4.08); IVF, HR = 5.09 (4.04 to 6.40)]. Female age and duration of subfertility were significant predictors, without clear interaction with the relative effect of treatment.

LIMITATIONS, REASONS FOR CAUTION

We were unable to adjust for other potentially important predictors, e.g. measures of ovarian reserve, which were not available in the linked Grampian dataset that may have made predictions more specific. This study was conducted using single centre data meaning that it may not be generalizable to other centres. However, the model performed as well as previous models in reproductive medicine when externally validated using the Dutch cohort.

WIDER IMPLICATIONS OF THE FINDINGS

For the first time, it is possible to estimate the chances of conception following expectant management and different fertility treatments over time in couples with unexplained subfertility. This information will help inform couples and their clinicians of their likely chances of success, which may help manage expectations, not only at diagnostic workup completion but also throughout their fertility journey.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck, and Guerbet. None of the other authors declare any conflicts of interest.

A Multicenter Phase IV Study to Investigate the Immunogenicity of Recombinant Human Follicle-Stimulating Hormone and Its Impact on Clinical Outcomes in Females Undergoing Controlled Ovarian Stimulation

CONTEXT

Therapeutic proteins can cause immune responses, which may have clinical implications.

AIMS

The aim of the study was to assess the immunogenicity of recombinant human follicle-stimulating hormone (r-hFSH), when used for controlled ovarian stimulation (COS).

SETTINGS AND DESIGN

Prospective, multicenter study conducted at reproductive medicine clinics in India and Vietnam.

MATERIALS AND METHODS

A total of 285 women, aged 20-40 years, undergoing 354 COS cycles for either intrauterine insemination (IUI) or in vitro fertilization (IVF) were studied. The primary outcome measure was the incidence of development of anti-drug antibodies (ADA) and their neutralization potential. Other outcome measures were follicle development, dose and duration of r-hFSH, positive serum pregnancy test, clinical pregnancy, cycle cancellation, and adverse events (AEs).

STATISTICAL ANALYSIS USED

A sample size of 250 was planned. Descriptive statistics are presented.

RESULTS

Four patients tested positive for ADA after r-hFSH administration at different time points; all of them tested negative, subsequently. None were found to have neutralization potential. The mean dose and duration of r-hFSH were 816 IU and 8.1 days in IUI and 2183 IU and 9.5 days in IVF, respectively. The serum and clinical pregnancy rates were 12.4% and 11.6% in IUI and 32.7% and 29.9% in IVF cycles, respectively. Seven AEs were reported, including two cases of ovarian hyperstimulation syndrome; two AEs were judged to be serious.

CONCLUSIONS

The tested r-hFSH has very low immunogenic potential and did not lead to the development of neutralizing antibodies. The overall efficacy and safety of the drug were in-line with existing literature data, and no specific clinical impact of immunogenicity could be identified.

Prewash total motile count is a poor predictor of live birth in intrauterine insemination cycles

OBJECTIVE

To determine whether there is a relationship between prewash total motile count and live births in couples undergoing IUI.

DESIGN

Retrospective review in a single academic center.

SETTING

Not applicable.

PATIENT(S)

Couples with infertility undergoing ovulation induction with IUI between 2010 and 2014.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Live births.

RESULT(S)

Our cohort included 310 women who underwent 655 IUI cycles with a cumulative live birth rate (LBR) per couple of 20% and an LBR per cycle of 10%. A analysis yielded no correlation between prewash total motile count (TMC) and live births. No live births occurred with TMC <2 million sperms. Age had a significant negative relationship to LBR. A receiver operating characteristic analysis comparing age and live births indicated a significant decline in live births for women >37 years (90% sensitivity, 70% specificity). The LBR per couple was decreased to 7% in women >37 years compared with 25% in women <37 years.

CONCLUSION(S)

Prewash TMC is a poor predictor of live birth. There were no live births with prewash TMC <2 million sperms. The LBR for women >37 years with IUI was significantly lower than women <37 years.

Growing body of evidence supports intrauterine insemination as first line treatment and rejects unfounded concerns about its efficacy, risks and cost effectiveness

IUI has been practiced for five decades but only three unconvincing trials attempted to demonstrate the superiority of IUI over sexual intercourse (SI). In the absence of evidence of its effectiveness, the National Institute for Clinical Excellence (NICE) recommended IVF over IUI after 2 years of unprotected SI. High-quality recent data in well-constructed studies suggest that biases against IUI procedures and in favour of IVF are invalid. It is unethical to continue to misinform patients and stakeholders. The well-constructed randomised controlled trials (RCT) show IUI procedure to be efficient, with minimal risk, and above all improved cost-effectiveness when compared to IVF for live birth. IUI as first-line treatment should be offered to most patients, while funding agencies and stakeholders need to be urgently informed of the cost-benefit in offering IUI. Fertility clinics, IVF interest groups, and regulatory bodies should amend their patient information and guidance to state that IUI should be the first line treatment and that IVF should be offered only when essential. Reappraising and promoting IUI based on evidence enhances patient autonomy, choices, and trust, while allowing the fertility industry to operate within an ethical and acceptable framework not seen as exploitative toward vulnerable patients.

IUI: review and systematic assessment of the evidence that supports global recommendations

BACKGROUND

IUI with or without ovarian stimulation (OS) has become a first-line treatment option for many infertile couples, worldwide. The appropriate treatment modality for couples and their clinical management through IUI or IUI/OS cycles must consider maternal and perinatal outcomes, most notably the clinical complication of higher-order multiple pregnancies associated with IUI-OS. With a current global emphasis to continue to decrease maternal and perinatal mortality and morbidity, the World Health Organization (WHO) had established a multi-year project to review the evidence for the establishment of normative guidance for the implementation of IUI as a treatment to address fertility problems, and to consider its cost-effectiveness for lower resource settings.

OBJECTIVE AND RATIONALE

The objective of this review is to provide a review of the evidence of 13 prioritized questions that cover IUI with and without OS. We provide summary recommendations for the development of global, evidence-based guidelines based upon methodology established by the WHO.

SEARCH METHODS

We performed a comprehensive search using question-specific relevant search terms in May 2015. For each PICO (Population, Intervention, Comparison and Outcomes) drafted by WHO, specific search terms were used to find the available evidence in MEDLINE (1950 to May 2015) and The Cochrane Library (until May 2015). After presentation to an expert panel, a further hand search of references in relevant reviews was performed up to January 2017. Articles that were found to be relevant were read and analysed by two investigators and critically appraised using the Cochrane Collaboration's tool for assessing risk of bias, and AMSTAR in case of systematic reviews. The quality of the evidence was assessed using the GRADE system. An independent expert review process of our analysis was conducted in November 2016.

OUTCOMES

This review provides an assessment and synthesis of the evidence that covers 13 clinical questions including the indications for the use of IUI versus expectant management, the sperm parameters required, the best and optimal method of timing and number of inseminations per cycle, prevention strategies to decrease multiple gestational pregnancies, and the cost-effectiveness of IUI versus IVF. We provide an evidence-based formulation of 20 recommendations, as well as two best practice points that address the integration of methods for the prevention of infection in the IUI laboratory. The quality of the evidence ranges from very low to high, with evidence that may be decades old but of high quality, however, we further discuss where critical research gaps in the evidence remain.

WIDER IMPLICATIONS

This review presents an evidence synthesis assessment and includes recommendations that will assist health care providers worldwide with their decision-making when considering IUI treatments, with or without OS, for their patients presenting with fertility problems.

Are we choosing the correct FSH starting dose during controlled ovarian stimulation for intrauterine insemination cycles? Potential application of a nomogram based on woman's age and markers of ovarian reserve

PURPOSE

To evaluate the potential application of a nomogram based on woman's age and ovarian reserve markers as a tool to optimize the follicle-stimulating hormone (FSH) starting dose in intrauterine insemination (IUI) cycles.

METHODS

We conducted a retrospective analysis enrolling 179 infertile women undergoing controlled ovarian stimulation (COS), followed by IUI. Each woman received an FSH starting dose according to clinical decision. After collecting data about COS and IUI procedures, we calculated the FSH starting dose according to the nomogram. The main outcomes measured were women's baseline characteristics, COS, and clinical outcomes.

RESULTS

The FSH starting dose calculated by the nomogram was significantly lower than the one actually prescribed (p < 0.001), in only 14.8% of the cycles nomogram calculated a higher starting dose. When gonadotropin dose was decreased during COS, and similarly in case of hyper-response (more than two follicles ≥ 16 mm retrieved), the FSH starting dose calculated by the nomogram would have been lower in most of the cases (81.8% and 48.8%, respectively). Conversely, when gonadotropin dose was increased during COS and in case of low ovarian response (no follicle ≥ 16 mm retrieved), the FSH starting dose calculated by the nomogram would have been lower in most of the cases (64.7% and 100%, respectively); in these groups median anti-Müllerian hormone (AMH) level was 5.62 ng/mL.

CONCLUSIONS

The application of this nomogram in IUI cycles would lead to a more tailored FSH starting dose and improved cost-effectiveness, although in PCOS women, particularly the ones with high AMH, it does not seem adequate.

Pilot study of the optimal protocol of low dose step-up follicle stimulating hormone therapy for infertile women

PURPOSE

To evaluate the optimized protocol of low dose follicle-stimulating hormone (FSH) therapy that has a starting dose of 50 IU/62.5 IU with a small increment dose (12.5 IU) for women with World Health Organization (WHO) II ovulatory disorder and unexplained infertility.

METHODS

Anovulatory women with WHO group II ovulatory disorder (ovulation induction [OI] patients, n = 29), and with an unexplained infertility (ovarian stimulation [OS] patients, n = 21) were enrolled. The protocol of low dose step-up FSH therapy was optimized for the starting dose as 50 IU (body mass index [BMI] < 20 group) and 62.5 IU (BMI ≥ 20 group) with the increment dose of 12.5 IU. Study outcomes were ovulation, monofollicular development and other variables.

RESULTS

In the OIpatients, the ovulation rate was 100% (BMI < 20 group) and 90.9% (BMI ≥ 20 group). Monofollicular development was 80.0% (BMI < 20) and 77.3% (BMI ≥ 20). The pregnancy rate was 60% (3/5 BMI < 20) and 18.2% (4/22 BMI ≥ 20). There was no multiple pregnancy. In the OSpatients, the ovulation rate was 100%. Monofollicular development was 85.7% (BMI < 20) and 76.6% (BMI ≥ 20). No pregnancy was achieved in the OSpatients.

CONCLUSION

Optimized protocol of low dose FSH therapy setting a starting dose 50 IU/62.5 IU by BMI with an increment dose of 12.5 IU was safe and highly effective in WHO group II anovulatory patients. However, this protocol seemed uneffective for patients with unexplained infertility.

Optimization of laboratory procedures for intrauterine insemination: survey of methods in relation to clinical outcome

BACKGROUND

There is a wide practice variation of used methods and outcomes in IUI in fertility laboratories. Standardization of the IUI procedure is important for reducing inconsistency among laboratories in counseling infertile couples and in pregnancy results. The aim of the study was to evaluate the currently used laboratory procedures of IUI in Dutch fertility laboratories and their effect on IUI pregnancy results. Additionally, the methods for semen analysis (SA) were evaluated, as SA is related to IUI in terms of inseminated sperm number and IUI counseling.

MATERIAL AND METHODS

This questionnaire survey study was sent to laboratories participating in the Dutch external quality control program for semen analysis (SKML) and consisted of 46 questions concerning laboratory management, methods for semen analysis and IUI, and clinical results. The results were analyzed using univariable and multivariable logistic regression models.

RESULTS

A total of 52 laboratories (out of 99) provided information on used methodologies for SA or laboratory procedures of IUI and the organization of the laboratory. A wide variability was confirmed in used methods for both SA and IUI. Evaluation of pregnancy results obtained during 3 years (2013-2015) showed that specific used laboratory methods have a significant effect on the probability of becoming pregnant.

DISCUSSION AND CONCLUSION

Important to remark is that in this survey study cycle-specific data, including variables of the individual couples (age, stimulation protocol, etc), were not included and may have effects on the results. The reported results provide an overview of the current practice performance; however, the organization of fertility laboratories is changing rapidly. The use of standardized methods in IUI is important for optimizing the performance of care and improving pregnancy results. The knowledge on used procedures, however, is limited, and further research on factors involving SA and the IUI procedure is necessary.

Techniques used for IUI: is it time for a change?

STUDY QUESTION

Are the guidelines for the technical aspects of IUI (WHO, 2010) still in accordance with the current literature?

SUMMARY ANSWER

In general, the laboratory guidelines of the World Health Organization (WHO) are a suitable protocol, although the evidence is not always conclusive and some changes are advisable.

WHAT IS KNOWN ALREADY

Lack of standardization of the technical procedures required for IUI might result in inter-laboratory variation in pregnancy rates. Most centers still use their own materials and methods even though some guidelines are available.

STUDY DESIGN, SIZE, DURATION

A structural review focusing on the association between pregnancy rates and the procedures of semen collection (e.g. ejaculatory abstinence, collection place), semen processing (e.g. preparation method, temperature during centrifugation/storage), insemination (e.g. timing of IUI, bed rest after IUI) and the equipment used.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A literature search was performed in Medline and the Cochrane library. When no adequate studies of the impact of a parameter on pregnancy results were found, its association with sperm parameters was reviewed.

MAIN RESULTS AND THE ROLE OF CHANCE

For most variables, the literature review revealed a low level of evidence, a limited number of studies and/or an inadequate outcome measure. Moreover, the comparison of procedures (i.e. semen preparation technique, time interval between semen, collection, processing and IUI) revealed no consensus about their results. It was not possible to develop an evidence-based, optimal IUI treatment protocol.

LIMITATIONS, REASONS FOR CAUTION

The included studies exhibited a lack of standardization in inclusion criteria and methods used.

WIDER IMPLICATIONS OF THE FINDINGS

This review emphasizes the need for more knowledge about and standardization of assisted reproduction technologies. Our literature search indicates that some of the recommendations in the laboratory guidelines could be adapted to improve standardization, comfort, quality control and to cut costs.

STUDY FUNDING/COMPETING INTEREST(S)

The Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands. S.K. and W.N. have no conflicts of interest to disclose. C.B. and A.W. are members of the board of the SKML. With a grant from SKML, L.L. was paid for her time to perform the research and write the publication. D.B. received grants from Merck Serono, Ferring and MSD, outside the submitted work.

REGISTRATION NUMBER

N/A.

IUI and IVF for unexplained subfertility: where did we go wrong?

IUI is a first-line treatment for couples with unexplained or mild male subfertility and has become one of the most widely used fertility-enhancing treatments. The results of a recent trial comparing IVF to IUI, demonstrating similar live birth rates, have been used to build a case supporting the effectiveness of IUI. Yet, this conclusion might be somewhat premature, as the superiority of neither IUI nor IVF over no treatment has ever been proven. The evidence on the effectiveness and safety of IUI and IVF has been evaluated in two Cochrane reviews which both suggested that there is insufficient evidence to conclude that IUI or IVF is effective compared to sexual intercourse in couples with unexplained subfertility. Recommendations for clinical practice have been given in the most recent National Institute for Health and Care Excellence fertility guideline that advises not to offer IUI any longer and suggests 2 years of sexual intercourse followed by IVF. This recommendation has generated an ongoing debate, with only 4% of all gynecologists in the UK discontinuing the use of IUI. We feel that it is high time to provide proper scientific evidence for the effectiveness of IUI, or lack thereof, and invite the medical community to start RCTs comparing IUI to sexual intercourse.

A New Dawn for Intrauterine Insemination: Efficient and Prudent Practice will Benefit Patients, the Fertility Industry and the Healthcare Bodies

This review addresses the misplaced facts about the IUI procedure within a lucrative fertility industry. Evidence suggests IUI must be a first-line treatment option for most couples except in cases of bilateral tubal blockage and severe oligozoospermia. We introduce the concept of using 'consecutive ejaculation' in men with subfertility and one which can radically alter the male infertility definition, thereby providing a new approach to examining and managing male factor infertility. The review also explores various aspects affecting the IUI procedure, its determinants of success, risks and areas for future improvements. Areas such as choice of patients, clinical management of patients, the type of stimulation regime, timing and the management of sperm usage have significant bearing to whether IUI will succeed. The paper asserts that IUI should be the first choice of fertility treatment.

Replacing IUI with IVF for initial treatment of unexplained infertility: why this NICE recommendation is cause for concern

The latest guidelines from the National Institute for Health and Care Excellence (NICE) for assisted conception recommend that people experiencing unexplained infertility should no longer be offered stimulated intra-uterine insemination (IUI) as a first-line treatment, but rather be directed towards IVF or alternatively be left to expectant management. NICE has acknowledged that the cited evidence leading to this decision was not sufficiently robust. As such, we are concerned that accordance with these new NICE guidelines may result in people with no identifiable cause of their infertility being prematurely referred for IVF treatment. Since IVF constitutes a more invasive and expensive treatment process, which also represents an additional and unnecessary cost pressure to the National Health Service, there is a longstanding need for a robust clinical trial to resolve the uncertainty as to whether one treatment is more appropriate than another. Until such data is available, we suggest that provision of stimulated IUI, in centres achieving a satisfactory live birth rate, represents a significant cost-saving to those commissioning fertility services, with lower risks to people treated.