IUI 2011

1. IUI 2011 Prof. Dr. Esat ORHON

2. Ovarian stimulation protocols(anti-oestrogens, gonadotrophinswith and without GnRHagonists/antagonists)for intrauterine insemination (IUI) in women with subfertility (Review) The Cochrane Library 2011, Issue 6 Cantineau AEP, Cohlen BJ

3. Robust evidence is lacking • Gonadotrophins might be the most effective drugs with IUI • Low dose protocols are advised • pregnancy rates do not differ from pregnancy rates which result from highdose regimen • the chances to encounter negative effects from ovarian stimulation such as multiples and OHSS

4. Anti-oestrogens Cost effective but less effective whencomparedto gonadotrophins. Do not prevent multiplepregnancies Haveanti-oestrogeniceffect on the endometrium Gonadotrophins Most effective drugs forIUI Low dose protocols (50 to 75 IU per day) are advised Pregnancy rates do not seemto differ significantly frompregnancyrates with high dose regimens (> 75 IU per day) whereas thechanges to encounter negative effects from ovarian stimulation,such as the risk ofmultiples and the risk ofOHSSmight be higherwithhighdoseprotocols. GnRH-agonists There seems to be no role in IUI programs Increase costs Increasemultiples without increasing the probability of conception Urinarygonadotrophinsversus Recombinant products There is no significant difference GnRH-antagonists Whether or not are going to play a role inmild ovarian hyperstimulation/IUI programs needs to be determined in futuretrials. Letrozole There is no convincing evidence thatLetrozoleis superior to clomiphene citrate and therefore the costshould be taken into account when using anti-oestrogens.

14. Synchronised approach for intrauterine insemination in subfertile couples. (Review)The Cochrane Library 2010, Issue 4 Cantineau AEP, Janssen MJ, Cohlen BJ

15. There is no evidence to advise one particular treatment option over another. • Since different time intervals between hCG and IUI did not result in differentpregnancy rates, a more flexible approach might be allowed. • The choice should be based on hospital facilities, conveniencefor the patient, medical staff, costs and drop-out levels.

22. Soft versus firm catheters for intrauterine insemination (Review)van der Poel N, Farquhar C, Abou-Setta AM, Benschop L, Heineman MJThe Cochrane Library 2010, Issue 11

23. There was no evidence of a significant effect difference regarding the choice of catheter type for any of the outcomes. • On the basis of the evidence available in this review, no specific conclusion can be made regarding the superiority of one catheter classover another. • Further adequately powered studies reporting on clinical outcomes (e.g. live birth rate) are required. • Additional outcomessuch as miscarriage rates and measures of discomfort need to be reported.

30. Single versus double intrauterine insemination (IUI) in stimulated cycles for subfertile couples (Review)Cantineau AEP, Heineman MJ, Cohlen BJ The Cochrane Library 2010, Issue 11 • six studies involving 1785 women. • There were no data for the main outcome measure of live birth per couple or ongoingpregnancy rates, and no authors presented comparative data for adverse events. • The results of five studies that reported pregnancy rateper couple showed a significant effect of using double insemination • OR 1.8, • 95% CI • 1.4 to 2.4

31. Based on the results of pregnancy rate per couple in five trials, double intrauterine insemination resulted in significant benefit oversingle intrauterine insemination in the treatment of subfertile couples with husband semen.

32. Pro

35. Con Double versus single intrauterine insemination for unexplained infertility: a meta-analysis of randomized trialsNikolaos P. Polyzos, M.D.,a Spyridon Tzioras, M.D., Ph.D.,a Davide Mauri, M.D., Ph.D.,a and Athina Tatsioni, M.D., Ph.D.b, Fertil Steril 2010;94:1261–6 • Six randomized trials, involving 829 women, were included in the analysis. • Fifty-four (13.6%) clinicalpregnancies were recorded for treatment with double IUI and 62 (14.4%) for treatment with single IUI. • There wasno significant difference between the single and double IUI groups in the probability for clinical pregnancy • (oddsratio, 0.92; 95% confidence interval, 0.58–1.45; P¼0.715) • Conclusion: Double IUI offers no clear benefit in the overall clinical pregnancy rate in couples with unexplained infertility.

37. Intra-uterine insemination versus timed intercourse or expectant management for cervical hostility in subfertile couples (Review)Helmerhorst FM, Van Vliet HAAM, Gornas T, Finken MJ, Grimes DAThe Cochrane Library 2010, Issue 11 • Each study was too small for aclinically relevant conclusion. • Only one of the studies provided information on important outcomes such as spontaneous abortion,multiple pregnancies, but none of studies reported on the occurrence of e.g. ovarian hyperstimulation syndrome. • There is no evidence from the published studies that intrauterine insemination is an effective treatment for cervical hostility. • Giventhe poor diagnostic and prognostic properties of the postcoital test and the observation that the test has no benefit on pregnancy rates,intrauterine insemination (with or without ovarian stimulation) is unlikely to be a useful treatment for putative problems identified by postcoital testing

38. Clomiphene citrate for unexplained subfertility in women (Review)Hughes E, Brown J, Collins JJ, Vanderkerchove P The Cochrane Library 2010, Issue 1 • Data relating to 1159 participants from seven trials were collated. • There was no evidence that clomiphene citrate was more effectivethan no treatment or placebo for live birth (odds ratio (OR) 0.79, 95% CI 0.45 to 1.38; P = 0.41) or for clinical pregnancy per womanrandomised both • with intrauterine insemination (IUI) • (OR 2.40, 95% CI 0.70 to 8.19; P = 0.16), • without IUI • (OR 1.03, 95% CI0.64 to 1.66; P = 0.91)

44. Intra-uterine insemination for unexplained subfertility (Review)Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ, Te Velde EThe Cochrane Library 2010, Issue 11 • 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 IUIwith 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 trialsprovided 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 IUIwith OH compared with TI in a natural cycle • (one RCT, 51 women: OR 4.05, 95% CI 0.39 to 41.87).

45. There is evidence that IUI with OH increases the live birth rate compared to IUI alone. • The likelihood of pregnancy was also increasedfor treatment with IUI compared to TI both in stimulated cycles. • There is insufficient data on multiple pregnancies and other adverseevents for treatment with OH. • Therefore, couples should be fully informed about the risks of IUI and OH as well as alternative treatment options.