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Chronopoulou E, Gaetano-Gil A, Shaikh S, Raperport C, Al Wattar BH, Ruiz-Calvo G, Zamora J, Bhide P. Optimizing intrauterine insemination: A systematic review and meta-analysis of the effectiveness and safety of clinical treatment add-ons. Acta Obstet Gynecol Scand 2024; 103:1919-1932. [PMID: 38961556 PMCID: PMC11426219 DOI: 10.1111/aogs.14858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Intrauterine insemination (IUI) is one of the most widespread fertility treatments. However, IUI protocols vary significantly amongst fertility clinics. Various add-on interventions have been proposed to boost success rates. These are mostly chosen arbitrarily or empirically. The aim of this systematic review and meta-analysis is to assess the effectiveness and safety of add-on interventions to the standard IUI protocol and to provide evidence-based recommendations on techniques used to optimize the clinical outcomes of IUI treatment. MATERIAL AND METHODS Systematic review and meta-analyses were performed in accordance with PRISMA guidelines. A computerized literature search was performed from database inception to May 2023. Randomized controlled trials (RCTs) were included reporting on couples/single women undergoing IUI with any protocol for any indication using partner's or donor sperm. A meta-analysis based on random effects was performed for each outcome and add-on. Three authors independently assessed the trials for quality and risk of bias and overall certainty of evidence. Uncertainties were resolved through consensus. Primary outcomes were ongoing pregnancy rate (OPR) or live birth rate (LBR) per cycle/per woman randomized. Registration number PROSPERO: CRD42022300857. RESULTS Sixty-six RCTs were included in the analysis (16 305 participants across 20 countries). Vaginal progesterone as luteal phase support in stimulated cycles was found to significantly increase LBR/OPR (RR 1.37, 95% CI 1.09-1.72, I2 = 4.9%) (moderate/low certainty of the evidence). Endometrial scratch prior/during stimulated IUI cycles may increase LBR/OPR (RR 1.44, 95% CI 1.03-2.01, I2 = 1.8%), but evidence is very uncertain. Results from two studies suggest that follicular phase ovarian stimulation increases LBR/OPR (RR 1.39, 95% CI 1.00-1.94, I2 = 0%) (low certainty of evidence). No significant difference was seen for the primary outcome for the other studied interventions. CONCLUSIONS The findings of this systematic review and meta-analysis suggest that vaginal luteal phase progesterone support probably improves LBR/OPR in stimulated IUI treatments. In view of moderate/low certainty of the evidence more research is needed for solid conclusions. Further research is also recommended for the use of endometrial scratch and ovarian stimulation. Future studies should report on results according to subfertility background as it is possible that different add-ons could benefit specific patient groups.
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Affiliation(s)
| | - Andrea Gaetano-Gil
- Clinical Biostatistics Unit, Hospital Universitario Ramon y Cajal (IRYCIS), Madrid, Spain
| | | | - Claudia Raperport
- London North West University Healthcare NHS Trust, London, UK
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Bassel H Al Wattar
- Institute for Women's Health, University College London, London, UK
- Women's Health Department, University College London Hospital, London, UK
| | - Gabriel Ruiz-Calvo
- Clinical Biostatistics Unit, Hospital Universitario Ramon y Cajal (IRYCIS), Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Universitario Ramon y Cajal (IRYCIS), Madrid, Spain
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health CIBERESP), Clinical Biostatistics, Madrid, Spain
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Baradwan S, Alshahrani MS, Miski NT, Alkhamis WH, Alfaifi SS, Abdelhakim AM, Sunoqrot M, Ahmaro M, Abdelazem O, Mohammed AH, Abbas AM, Bakry MS. Ultrasound guidance versus classical method for intrauterine insemination: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2021; 263:223-230. [PMID: 34242930 DOI: 10.1016/j.ejogrb.2021.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There is a great controversy regarding the benefits of ultrasound-guided intrauterine insemination (IUI) in improving pregnancy rates. Thus, we aimed to compare ultrasound-guided IUI versus classical IUI regarding the pregnancy rates improvement. METHODS A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during June 2021. We selected randomized clinical trials (RCTs) that compared ultrasound-guided IUI versus classical IUI in different pregnancy outcomes. We extracted the available data from included studies and pooled them in a meta-analysis model using RevMan software. Our primary outcome was clinical pregnancy rate. Our secondary outcomes were miscarriage, live birth rates, and incidence of difficulty reported during the procedure. The overall quality of evidence was assessed through GRADEpro GDT software. RESULTS Seven RCTs met our inclusion criteria with a total number of 1338 patients. We found that ultrasound-guided IUI significantly improved the clinical pregnancy rate when compared to the classical group (RR = 1.33, 95% CI [1.05, 1.68], p = 0.02). However, there were no significant differences between both groups in terms of miscarriage and live birth rates. Ultrasound-guided IUI significantly reduced the incidence of difficulty reported during the procedure (RR = 0.42, 95% CI [0.21, 0.84], p = 0.01). The GRADEpro GDT tool showed high quality of evidence for the evaluated outcomes. CONCLUSIONS There is evidence of high quality that ultrasound-guided IUI improves the pregnancy rate and reduces the incidence of difficulty reported during the procedure.
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Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Majed Saeed Alshahrani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Najran University, Najran, Saudi Arabia
| | - Najlaa Talat Miski
- Department of Obstetrics and Gynecology, Faculty of Medicine at Rabigh, King Abdulaziz University, Saudi Arabia
| | - Waleed H Alkhamis
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Suhail S Alfaifi
- Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Mohammad Sunoqrot
- College of Medicine and Health Sciences, Palestine Polytechnic University, Hebron, Palestine
| | - Manar Ahmaro
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Osama Abdelazem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Ahmed Hashim Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Egypt
| | - Mohamed Sobhy Bakry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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Thanaboonyawat I, Charanwetprasert M, Boriboonhirunsarn D, Petyim S, Laokirkkiat P. Ultrasound guidance versus the classical method for intrauterine insemination in oral medication-stimulated cycles: A randomized, single-blind, controlled trial. Eur J Obstet Gynecol Reprod Biol 2021; 258:278-282. [PMID: 33494027 DOI: 10.1016/j.ejogrb.2021.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/23/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study was conducted to compare the pregnancy rates of ultrasound-guided intrauterine insemination (UG-IUI) and classical intrauterine insemination (C-IUI) cycles. STUDY DESIGN A total of 320 infertile women were enrolled and randomized into an UG-IUI group, and a C-IUI group. All participants received an oral medication for ovarian stimulation. With both groups, the IUIs were scheduled and performed by doctors in their residency and fellowship training, under supervision. The duration and difficulty of the procedures were assessed. A pregnancy test was offered 3 weeks later if the participants did not have menstruation. RESULTS The demographic and other baseline characteristics of the groups (baseline hormone levels, cervical length, uterine position, endometrial thickness, and expertise of the providers) were comparable. The pregnancy rates were similar, with 6.9 % and 6.3 % for the UG-IUI and C-IUI groups, respectively. In the UG-IUI group, the pregnancy rate of the multigravida women was three times higher than that of the nulligravida women (15.4 % vs. 5.0 %; p = 0.13). Although the duration of the procedure was shorter for the UG-IUI group (p < 0.05), the level of difficulty was similar for the two groups. CONCLUSIONS For oral-medication stimulated cycles, UG-IUI did not increase the pregnancy rate more than with C-IUI. However, the pregnancy rate tended to increase with UG-IUI for multigravida women.
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Affiliation(s)
- Isarin Thanaboonyawat
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand; Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| | - Manita Charanwetprasert
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Dittakarn Boriboonhirunsarn
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Somsin Petyim
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand; Stem Cell Research and Development Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand; Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| | - Pitak Laokirkkiat
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand; Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
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