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Intrauterine insemination (IUI) is often used in the treatment of couples with various reasons for infertility, including: cervical factor, ovulation disorders (complete absence of ovulation or irregular ovulation), immunological factors (formation of sperm antibodies in the female body), male factor (when sperm count decreases, necessary for natural conception, but sufficient for intrauterine insemination) and infertility of unspecified origin.
The overall success rate of IUI remains controversial, as it depends on a combination of reasons and ranges from 5-70% (the world average is 11-20% per cycle).
IUI can be carried out both in the natural cycle and in combination with controlled stimulation of ovulation.
In this material, we will discuss the following questions:
- Analysis of the success of IUI in male and unexplained infertilitу
- Percentage of successful IUI cycles according to the treatment strategy
- Economic effectiveness of IUI as an option for achieving pregnancy
Natural cycle in comparison with follicular growth stimulation during IUI.
1. Male subfertility:
Some of the first studies (Nulsen et al., 1993; Cohlen et al., 1998) indicate that the use of gonadotropins with IUI increases the frequency of pregnancy compared to IUI performed independently.
However, in 2016, a systematic review (Cissen M. et al.) concluded that data on the overall effectiveness of intrauterine insemination for the treatment of male infertility are inconclusive and require further study.
2. Unspecified infertility:
In this case, both clomiphene citrate and the use of gonadotropins in combination with IUI increase the frequency of pregnancy compared to IUI without follicular growth stimulation.
In 2015, they received data from a multicenter randomized study, where different groups of patients were prescribed gonadotropins, letrozole, and clomiphene citrate for stimulation of ovulation in combination with IUI. The following results were obtained: the highest frequency of live birth was in the group where gonadotropins were used for stimulation; no significant differences were found in groups using clomiphene citrate and letrozole.
Anticipation of ovulation or induction of ovulation and frequency of insemination.
The time of ovulation is one of the decisive factors that determines the success of IUI. The main goal of treatment is to obtain sperm that are able to fertilize an egg during a short window of time, the so-called periovulatory period.
To monitor ovulation, use:
· conducting folliculometry (ultrasound monitoring of follicle growth and readiness of the endometrium for subsequent embryo implantation);
· chorionic gonadotropin (hCG) injection to initiate ovulation.
The advantages of injecting human chorionic gonadotropin is that we can better control the cycle and accurately determine the time of ovulation (ovulation should occur 36-44 hours after the hCG injection).
A prospective randomized study in 449 cycles (controlled ovarian stimulation combined with insemination) showed an increase in pregnancy rates in cycles with double insemination at 12 h and 36 h after the introduction of chorionic gonadotropin compared to a single insemination.
Economic efficiency
Two randomized controlled trials have confirmed the cost-effectiveness of intrauterine insemination versus IVF for couples with unexplained infertility as first-line treatment. It was important that a woman’s reproductive age has a very decisive effect on the effectiveness of the treatment.
It can be concluded that intrauterine insemination is a useful and cost-effective method of overcoming some causes of infertility. The frequency of pregnancy during 4-6 cycles of IUI is optimal.
However, pay attention to: duration of infertility, ovarian reserve (the reserve of eggs, which is always individual and may not correspond to reproductive age), female reproductive age, partner’s age, surgery on the ovaries in the past, pelvic inflammatory disease, endometriosis, severe male factor (pronounced deviation of indicators in the number, quality or mobility of sperm) – these are all unfavorable factors for the use of intrauterine insemination and will have low efficiency.
It is important to remember that in order to carry out IUI, the patency of the fallopian tubes must be confirmed, inflammatory processes of the pelvic organs must be excluded, endometrial polyps and nodes of the uterus that deform its cavity, the glenoid (adhesion process) of the pelvic organs must be excluded, and the normal karyotype of the family must be confirmed couples Women under the age of 35 should have an IUI with a normal ovarian reserve.
Whereas the cervical factor, infertility of unknown origin, anovulatory causes of non-pregnancy (in the absence of regular ovulation), male subfertility are more favorable from the point of view of the effectiveness of intrauterine insemination.
Also, carrying out IMI in the event of violation of the growth of the optimal thickness of the endometrium (in the case of hypoplasia of the endometrium – thickness less than 8.0 mm on the day of ovulation) – at the same time, we medically stimulate the growth of dominant follicles (no more than 2), grow the endometrium, perform IMI, as a rule, twice before ovulation and on the day of ovulation and we support the second phase of the menstrual cycle, in which the implantation of the embryo should take place, which increases the probability of fertilization and attachment of the embryo in the uterine cavity.
Adding controlled stimulation of the ovaries to intrauterine insemination increases the effectiveness of this method, but carries the risk of multiple pregnancy (therefore, it should be carried out by an experienced reproductive specialist – with the growth of no more than two dominant follicles) and the correct synchronization of the endometrium for further implantation of the embryo.
Reproductive medicine, like medicine in general, requires clarity, correct examination, experience of a reproductive specialist and an individual approach to each case, because all factors must be taken into account when choosing tactics.