Cervical insemination versus intra-uterine insemination of donor sperm for subfertility

Insemination of donor sperm is a fertility treatment for women who are unable to conceive with their partner or are single. There are two techniques of insemination; the sperm can be deposited either in the cervix or in the uterus. The purpose of this review is to determine whether pregnancy outcomes are improved using intra-uterine insemination (IUI) in comparison to cervical insemination (CI) in women undergoing insemination with donor sperm. Of the 232 studies found, four studies were included in this review. All of the included studies used cryopreserved sperm. In two studies women had gonadotrophin-stimulated cycles and in two studies women had clomiphene-stimulated cycles. The rates of live birth and pregnancy improved with IUI. Therefore, this review supports the use of IUI instead of CI for donor insemination.

Authors' conclusions: 

The findings of this review support use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.

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Background: 

Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples.
Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus.
Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates.

Objectives: 

To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm.

Search strategy: 

The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved.

Selection criteria: 

Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available.

Data collection and analysis: 

Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed.

Main results: 

The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96).

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