Effectiveness and safety of intrauterine insemination vs. assisted reproductive technology

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Effectiveness and safety of intrauterine insemination vs. assisted reproductive technology

Authors:

Gulam Bahadur1,2 , Roy Homburg2

1Reproductive Medicine Unit, North Middlesex University Hospital, Old Admin Block, Sterling Way, London N18 1QX, UK
2Homerton Fertility Unit, Homerton University Hospital, Homerton Row, London E9 6SR, UK

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We followed the paper (1) with interest stating that 3 cycles of IUI would result in a similar probability of live birth as 1 cycle of IVF (26.3% vs. 27.3%), but with lower risks of multiple birth, preterm infants, NICU admission, and gestational diabetes. The results were similar in women with infertility of unspecified origin and in women aged 18–40 years. The 3:1 IUI:IVF relationship is already well established (2). However, in our large UK real-time contemporary practices this is more of a 2.35:1 relationship which improves to a 1.73: 1, IUI: IVF cycles with clinics going from the mean of 12.1% to 15.6% LBR, with extraordinary cost benefits of IUI over IVF (3,4). It is IVF which was the significant contributor to multiple births compared to IUI providing a UK national cost burden of £115 082 017 for IVF compared with £2 940 196 for IUI for maternal and neonatal risks. At baseline success rates of IUI and IVF, it was £42 558 cheaper to gain an IUI baby compared to IVF (4).  IVF procedures were also associated with terminations and fetal reduction while severe OHSS risks were higher than IUI.

The NICE guidelines which affect only England and Wales have been seized by global IVF practitioners to promote expensive IVF, but this was not based on evidence, and need urgent review (5). Clearly, the message (1, 4, 5) along with that of ASRM (6) is that funding agencies and fee-paying patients should insist on IUI as first line treatment before IVF, primarily to reduce maternal and neonatal risks as well as significantly reduce costs.

References: 

  1. Chiu YH, Yland JJ, Rinaudo P, Hsu J, McGrath S, Hernández-Díaz S, Hernán MA. Effectiveness and safety of intrauterine insemination vs. assisted reproductive technology: emulating a target trial using an observational database of administrative claims. FertilSteril. 2022 Mar 16:S0015-0282(22)00114-5. doi: 10.1016/j.fertnstert.2022.02.003. Epub ahead of print. PMID: 35305813.
  2. Nandi A, Bhide P, Hooper R, Gudi A, Shah A, Khan K, Homburg R. Intrauterine insemination with gonadotropin stimulation or in vitro fertilization for the treatment of unexplained subfertility: a randomized controlled trial. FertilSteril. 2017 Jun;107(6):1329-1335.e2. doi: 10.1016/j.fertnstert.2017.03.028. Epub 2017 May 10. PMID: 28501361.
  3. Bahadur G, Homburg R, Bosmans JE, Huirne JAF, Hinstridge P, Jayaprakasan K, Racich P, Alam R, Karapanos I, Illahibuccus A, Al-Habib A, Jauniaux E. Observational retrospective study of UK national success, risks and costs for 319,105 IVF/ICSI and 30,669 IUI treatment cycles. BMJ Open. 2020 Mar 16;10(3):e034566. doi: 10.1136/bmjopen-2019-034566. PMID: 32184314; PMCID: PMC7076239.
  4. Bahadur G, Homburg R, Muneer A, Racich P, Jayaprakasan K, Acharya S, Jauniaux E. Global inequality in sub-fertility treatment needs safer, cost effective, evidence-based and economically viable choices for patients and stakeholders. JBRA Assist Reprod. 2022 Jan 17;26(1):1-2. doi: 10.5935/1518-0557.20210111. PMID: 35040304; PMCID: PMC8769187.
  5. Bahadur G, Woodward B, Homburg R, Al-Habib A, Muneer A. Pitfalls of NICE recommendations on fertility treatment. BMJ. 2017;356:j751. PMID: 28193611 DOI: 10.1136/bmj.j751
  6. Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org; Practice Committee of the American Society for Reproductive Medicine. Evidence-based treatments for couples with unexplained infertility: a guideline. Fertil Steril. 2020 Feb;113(2):305-322. doi: 10.1016/j.fertnstert.2019.10.014. PMID: 32106976.