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Evidence summaries

Intra-Uterine Insemination for Unexplained Subfertility

Intra-uterine insemination (IUI) with ovarian stimulation (OS) may be more effective than IUI alone for increasing live birth. IUI with OS may be more effective than expectant management for unexplained subfertility. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 15 trials involving a total of 2 068 women.

It was uncertain whether treatment with intra-uterine insemination (IUI) in a natural cycle improved live birth rate compared to treatment with expectant management (OR 1.60, 95% CI 0.92 to 2.78; 1 RCT, n=334), or IUI in a stimulated cycle improved live birth rates compared to treatment with timed intercourse (TI) in a stimulated cycle (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs, n=208). IUI combined with clomiphene citrate or letrozole resulted in a higher live birth rate compared to treatment with expectant management in a natural cycle (OR 4.48, 95% CI 2.00 to 10.01; 1 RCT; n=201). IUI in a natural cycle resulted in a higher cumulative live birth rate compared to treatment with expectant management in a stimulated cycle (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, n=342). IUI in a stimulated cycle resulted in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle (OR 2.07, 95% CI 1.22 to 3.50; 4 RCTs, n=396).

Another Cacrane review [Abstract] and a network meta-analysis 2 included 24 RCTs with 3 983 couples. Ten RCTs including 2 725 couples reported on live birth. For differences between OS, IUI, OS-IUI, or vitro fertilisation with or without intracytoplasmic (IVF/ICSI) versus expectant management see table (tableT1). This suggests that if the chance of live birth following expectant management is assumed to be 17%, the chance following OS, IUI, OS-IUI, and IVF would be 9% to 28%, 11% to 33%, 15% to 37%, and 14% to 47%, respectively. When only including couples with poor prognosis of natural conception (3 trials, 725 couples) OSIUI and IVF/ICSI increased LBR compared to expectant management (OR 4.48, 95% CI 2.00 to 10.1; moderate-certainty evidence; OR 4.99, 95 CI 2.07 to 12.04; moderate-certainty evidence), while there was insufficient evidence of a difference between IVF/ICSI and OS-IUI (OR 1.11, 95% CI 0.78 to 1.60; low-certainty evidence).Compared to expectant management, other treatments increased the odds of multiple pregnancy (11 RCTs, 2564 couples).

An open-label, randomised, controlled, two-centre trial 3 included 201 women with unexplained infertility. Women assigned to IUI had a higher cumulative livebirth rate than women assigned to expectant management (31% livebirths vs 9% livebirths; RR 3.41, 95% CI 1.71 to 6.79; p=0.0003).

Expectant management vs other interventions for infertility

Outcome: Live birth rate or ongoing pregnancyAssumed riskwith comparatorExpectant managementRisk with interventionRelative effect(95% CI)Numbe of couples (Studies)Quality of evidence
166 per 1000OS 167 per 1000(92 to 282)OR 1.01(0.51 to 1.98)527 (2)Low
166 per 1000IUI 194 per 1000(108 to 325)OR 1.45(0.61 to 2.43)386 (1) Low
166 per 1000OS-IUI 242 per 1000(149 to 369)OR 1.61(0.88 to 2.94)454 (2) Low
166 per 1000IVF/ICSI272 per 1000(139 to 465)OR 1.88(0.81 to 4.38)only indirect evidence used hereLow

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment) and by imprecise results (limited study size for each comparison).

    References

    • Ayeleke RO, Asseler JD, Cohlen BJ et al. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2020;(3):CD001838. [PubMed]
    • Wang R, Danhof NA, Tjon-Kon-Fat RI et al. Interventions for unexplained infertility: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023;(9):CD012692. [PubMed]
    • Farquhar CM, Liu E, Armstrong S et al. Intrauterine insemination with ovarian stimulation versus expectant management for unexplained infertility (TUI): a pragmatic, open-label, randomised, controlled, two-centre trial. Lancet 2018;391(10119):441-450. [PubMed]

Primary/Secondary Keywords