Middle East Fertility Society Journal Middle East Fertility Society ISSN: 1110-5690 Vol. 10, Num. 1, 2005, pp. 33-35

DEBATE

The current role of intrauterine insemination for the treatment of male factor and unexplained infertility

Aboubakr M. Elnashar, M.D.

Department of Obstetrics and Gynecology Benha University Hospital, Egypt

Code Number: mf05005

The place of intrauterine insemination (IUI), especially in relation to in vitro fertilization (IVF) remains controversial. There are wide variations in indications, protocols of ovarian stimulation, semen preparation, timing, number & technique of insemination. There are divergent opinions regarding the benefits obtained from IUI. Indications of IUI include unexplained infertility, male factor infertility, endometriosis, cervical factor infertility & male immunological infertility.

Unexplained infertility

Both stimulated & un-stimulated IUI are more effective than no treatment. Stimulated IUI is an effective treatment in unexplained infertility, but ovulation induction with timed intercourse has negligible impact (1). The likelihood of pregnancy is 3 times greater with IUI (2). However, it is recognized that stimulated IUI carries a risk of multiple pregnancy.

Male factor infertility

IUI is indicated for management of male factor infertility where semen is of sufficient quality for there to be 2 to 5 million motile sperm available after sperm preparation. However the specific semen criteria for the use in IUI vary from clinic to clinic.

Mild to moderate male infertility

IUI in natural cycles & IUI with COH significantly improved the probability of conception. IUI with COH is superior to TI with COH. IUI overcomes failure to fertilize due to impaired mucus penetration & poor survival in the female reproductive tract (3).

Severe male factor infertility

Severe male factor infertility is not a candidate for IUI but ICSI (4). ICSI is more cost effective than IUI when the mean total motile sperm count is <10 million.

Mild male infertility or unexplained infertility

IUI Vs IVF: The pregnancy rate per started cycle was 7.4% for IUI, 8.7% for IUI with COH, 12.2% for IVF (5). These differences did not reach statistical significance. IUI is as effective as IVF at 1/3 of the cost per pregnancy (6). Stimulated IUI should be the first choice treatment for mild male factor infertility or unexplained infertility. It has the same efficacy as stimulated IVF & is more cost-effective due to its lower cost.

Cervical factor infertility

Cervical factor infertility was diagnosed when postcoital test after 8-12h showed no sperms with progressive forward motion. IUI in natural cycle is an effective treatment for cervical factor infertility (7)

Male immunological infertility

Male immunological infertility was diagnosed when mixed antiglobulin reaction to IgG was positive. IUI is significantly better than limited intercourse with prednisolone (8). IUI is an effective method, results are obtained rapidly & steroid side effects can be avoided.

Endometriosis

Minimal & Mild endometriosis: Treatment with COH & IUI was associated with superior outcome both by crude live-birth rates & proportional hazard analysis (9).

The number of IUI attempts should be individualized depending on the needs of patients. In general, 85% of IUI pregnancies occurred during the first four cycles (10). Continued IUI is not recommended. Advancing female age decreases successful outcomes with IUI. Several studies have suggested that IUI should not be used in women aged >40 years. Other studies demonstrated that IUI is an appropriate treatment for this age group of women achieving a live birth of 8.5% per insemination (11).

In conclusion: stimulated IUI should be the first choice treatment for mild male factor infertility, unexplained infertility or minimal to mild endometriosis. In absence of tubal blockage & severe male factor, use of hMG-IUI is more cost effective than IVF. Four cycles of IUI are enough. 

REFERENCES 

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2. Hughes EG. Stimulated intra-uterine insemination is not a natural choice for the treatment of unexplained subfertility: 'Effective treatment' or 'not a natural choice'? Hum Reprod 2003;18(5):912-4.
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8. Lahteenmaki A, Veilahti J, Hovatta O. Intra-uterine insemination versus cyclic, low-dose prednisolone in couples with male antisperm antibodies. Hum Reprod 1995 Jan;10(1):142-7.
9. Tummon IS, Asher LJ, Martin JS, Tulandi T. Randomized controlled trial of superovulation and insemination for infertility associated with minimal or mild endometriosis. Fertil Steril 1997 Jul;68(1):8-12.
10. Isaksson R, Tiitinen A. Superovulation combined with insemination or timed intercourse in the treatment of couples with unexplained infertility and minimal endometriosis. Acta Obstet Gynecol Scand 1997 Jul;76(6):550-4.
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