Human Reproduction, Vol. 17, No. 11, 3003,
November 2002
© 2002 European Society of Human Reproduction and Embryology
Is the benefit of IUI really evidence-based?
78, bd Tixador, 66140 Canet en Roussillon, France
Correspondence: E-mail: herman.snick{at}freesbee.fr
Dear Sir,
Miskry and Chapman found that in many fertility centres within Australia and New Zealand, IVF was promoted as first line treatment instead of intrauterine insemination (IUI) (Miskry and Chapman, 2002
). They argue that the benefits of IUI compared with IVF are proven and therefore we are obliged to translate this in our practice.
Two systematic reviews demonstrated the superiority of IUI in improving the probability of conception in mild male and unexplained infertility (Hughes, 1997; Cohlen et al., 1999). A total of 21 of the 26 randomized controlled trials included in these meta-analyses used timed intercourse (TI) as no-treatment control. The timing of the intercourse was generally between 24 and 40 h after the LH surge or the injection of hCG. In seven publications sexual abstinence was advised in the remaining peri-ovulatory days, four times sexual activity was not further influenced and in 10 publications this was not stated. The pregnancy rate in the group with TI was adopted as the baseline to compare the efficacy of the therapeutical activities.
There are a lot of arguments to demonstrate that TI after the LH-surge is not as effective as spontaneous uninfluenced coital activity in achieving pregnancy. One study (Nulsen et al., 1987) found a rapid decline in cervical mucus quality in the 24 h period following the LH surge. This is confirmed by the finding of Wilcox et al. that the best days to realise a conception are the 2 days before, and the day of, ovulation (Wilcox et al., 1995). The probability of conception increases if there are several acts of intercourse in this period. The chance of achieving a pregnancy is close to zero the day after the ovulation (Wilcox et al., 1995).
The timing of the intercourse after the LH peak reduces the probability of conception. Timed intercourse is therefore not an appropriate no-treatment control and the conclusions of the two meta-analyses on the efficacy of IUI are not valid. On the other hand, the harm of this kind of treatment is clearly demonstrated (Elster, 2000).
We need more evidence of the benefit to perform IUI in mild male and unexplained infertility.
References
Cohlen, B.J., Vandekerckhove, P., te Velde, E.R. and Habbema, J.D.F. (1999) Timed intercourse versus intra-uterine insemination with or without ovarian hyperstimulation for subfertility in man (Cochrane Review). In The Cochrane Library, issue 3. Oxford Update Software.
Elster, N. (2000) Less is more: the risks of multiple births. Fertil. Steril., 74, 617–623.[Web of Science][Medline]
Hughes, E.G. (1997) The effectiveness of ovulation induction and intrauterine insemination in the treatment of persistent infertility: a meta-analysis. Hum. Reprod., 12, 1865–1872.
Miskry, T. and Chapman, M. (2002) The use of intrauterine insemination in Australia and New Zealand. Hum. Reprod., 17, 956–959.
Nulsen, J., Wheeler, C., Ausmanas, M. and Blasco, L. (1987) Cervical mucus changes in relationship to urinary luteinizing hormone. Fertil. Steril., 48, 783–786.[Web of Science][Medline]
Wilcox, A.J., Weinberg, C.R. and Baird, D.D. (1995) Timing of sexual intercourse in relation to ovulation: effects on the probability of conception, survival of the pregnancy and sex of the baby. N. Engl. J. Med., 333, 517–521.
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