8. (a) Intrauterine Insemination (IUI): IUI can be used with controlled ovarian stimulation. IUI without COS is of limited value unless there are barriers to sperm deposition such as male erectile dysfunction (ED) or male or female anatomic/physiologic/psychological problems. IUI can also be helpful with cryopreserved/thawed sperm.
Many clinicians combine clomiphene citrate with intrauterine insemination (IUI). Three randomized controlled trials have evaluated IUI alone as an empiric treatment for unexplained infertility (Bhattacharya, 2008; Guzick, 1999; Steures, 2007). In two trials involving 467 and 99 couples of women and men, the pregnancy rate in IUI cycles was 2.2% (95% CI 0.4, 4.1) higher than in control cycles (Guzick, 1999; Steures, 2007). In the other trial, which involved 384 couples of women and men, the pregnancy rates were 22% and 19% in treated and control groups, respectively (Bhattacharya, 2008). In the one trial with a difference in favour of IUI, the difference in pregnancy rates per cycle was small: 5% and 3% with IUI and intracervical insemination, respectively; and the duration of infertility was 3.7 years (Guzick, 1999). Intrauterine insemination alone as an empiric treatment should be reserved for couples with more than three years duration of infertility who are willing to accept a small increment in pregnancy rates. It may also be useful in some couples with sexual dysfunction. IUI with carefully prepared sperm is not associated with notable side effects. About 64% of studies suggest that a reasonable chance of success with IUI requires at least 5 million total motile sperm in the inseminate.
The combination of clomiphene citrate with IUI (CC/IUI) is commonly used as an empiric treatment, although there is limited evidence of its effectiveness. One crossover trial reported on 176 treatment cycles before the crossover. In the CC/IUI group, the pregnancy rate was 11% per cycle compared with 4% in the control group (95% CI -1.0,15.2) (Deaton, 1990). The results of a large management trial support this apparent benefit. Both arms received CC/IUI as an initial treatment, and the pregnancy rates were 7% and 8% per cycle and 19% and 22% after three cycles (Reindollar, 2010). Where facilities permit the use of CC/IUI treatment, a course of three cycles is a reasonable trial of empiric therapy.
- Fair evidence indicates clomiphene citrate treatment with intrauterine insemination achieves a pregnancy rate of about 7% per cycle.
- (b) Donor sperm: donor sperm can be used when available, appropriate and consistent with patient and society values and laws.
Where available and acceptable in cases of infertility due to azoospermia, timed intrauterine insemination of carefully selected and prepared donor semen is the most effective of all infertility treatments. The identification and screening of donors involve procedures that are laborious, although not technically demanding. Cryopreservation is necessary while awaiting the results of later testing for sexually transmitted infections. When three-to-six intrauterine insemination cycles are not successful, ICSI with donor sperm may be considered.