Intrauterine insemination versus timed intercourse with clomiphene citrate in polycystic ovary syndrome: a randomized controlled trial

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1 A C TA Obstetricia et Gynecologica MAIN RESEARCH ARTICLE Intrauterine insemination versus timed intercourse with clomiphene citrate in polycystic ovary syndrome: a randomized controlled trial HATEM ABU HASHIM 1, OSAMA OMBAR 2 & IBRAHIM ABD ELAAL 3 1 Department of Obstetrics & Gynecology, 2 Department of Diagnostic Radiology, and 3 Department of Clinical Pathology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt Key words Polycystic ovary syndrome, clomiphene citrate, intrauterine insemination, timed vaginal intercourse, pregnancy rate Correspondence Hatem Abu Hashim MD MRCOG, Associate Professor of Obstetrics & Gynecology. Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt. hatem_ah@hotmail.com Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Received: 1 August 2010 Accepted: 18 December 2010 DOI: /j x Abstract Objective. To compare the efficacy of intrauterine insemination vs. timed intercourse with clomiphene citrate as a first-line treatment for anovulatory infertility associated with polycystic ovary syndrome. Design. A randomized controlled trial following the CONSORT criteria. Setting. A university hospital and a private practice setting. Patients. 188 women (525 cycles) with polycystic ovary syndrome. Main outcome measures. Women received three consecutive cycles of ovulation induction with clomiphene citrate and intrauterine insemination (n=93, 259 cycles) or three consecutive cycles of clomiphene citrate with timed intercourse (n=95, 266 cycles). Outcome measures. Clinical pregnancy rate per cycle, number of growing and mature follicles, serum estradiol, endometrial thickness at the hcg day, serum progesterone, ovulation, miscarriage and live birth rates. Results. There were no differences between the two groups regarding the clinical pregnancy rate per cycle or per woman (8.49 vs. 7.89% and 23.6 vs. 22.1%; p=0.26 and p=0.33, respectively). Two twin pregnancies occurred in each group. Miscarriage and live birth rates were comparable (18.1 vs. 19% and vs %; p=0.31 and p=0.33, respectively). No ectopic, higher-order pregnancies or cases of ovarian hyperstimulation syndrome occurred. No differences were found regarding the number of follicles, serum progesterone, ovulation rates, estradiol levels or endometrial thickness at the hcg day (7.7±0.4 vs. 7.5±0.6mm; p=0.54). Conclusions. Ovulation induction with clomiphene citrate and timed intercourse is as effective as that with intrauterine insemination for achieving pregnancy in polycystic ovary syndrome and could represent the initial treatment option, being less invasive and less expensive than intrauterine insemination. Abbreviations: PCOS, polycystic ovary syndrome; CC, clomiphene citrate; IUI, intrauterine insemination; TI, timed vaginal intercourse; E2, estradiol; P, progesterone; FSH, follicle stimulating hormone; LH, luteinizing hormone; hcg, human chorionic gonadotrophin; BMI, body mass index. Introduction Polycystic ovary syndrome (PCOS) is a prevalent and heterogeneous condition affecting 6 10% of reproductive-age women and 35 40% of infertile women (1). It is the most common cause of chronic anovulation and is associated with hyperandrogenemia (1). Clomiphene citrate (CC) still maintains its place as the first-line therapy for ovulation induction in these women (2,3). Most clomiphene-induced pregnancies occur within the first three cycles of treatment (4 6). In a large randomized trial, Legro et al. (7) compared the effects of CC, metformin and combination therapy in 626 infertile women with PCOS. They reported an ovulation rate and clinical pregnancy rate per woman of 75.1 and 23.9%, and per cycle of 49% and 5.3%, respectively, after CC treatment. This discrepancy between ovulation and pregnancy rates may be explained by the peripheral anti-estrogenic effects of CC at the level of the endometrium and cervical mucus (8 12). 344

2 H. Abu Hashim et al. Insemination in polycystic ovary syndrome Currently, intrauterine insemination (IUI) with or without ovarian stimulation is widely used to treat male infertility and unexplained infertility, and for couples with minimal and mild endometriosis (13 17). The rationale of IUI treatment is to increase the rate of conception in the couple by increasing the chance that the maximum number of healthy sperm will reach the site of fertilization. However, in couples with abnormal cervical mucus, the rationale might be to bypass a possible cervical factor (16). A clinical pregnancy rate of 12.2% per cycle in women below 40 years was reported after IUI cycles with husband semen performed in European countries in 2003 (18). Kalu et al. (19) reported a clinical pregnancy rate of 12.6% per cycle following 478 CC/IUI cycles performed for women with unexplained infertility. Timed vaginal intercourse (TI) involves interfering with natural coital habits by asking couples to refrain from intercourse until some marker shows that ovulation is imminent. It is the usual control treatment in trials of IUI (20). There were no differences between pregnancy rates per couple for IUI vs. TI in stimulated cycles in male infertility (OR 1.67, 95% CI ) (14). In a randomized trial, Agarwal and Mittal (21) compared IUI and TI in superovulated cycles with CC in 140 couples with unexplained infertility. They reported a pregnancy rate of 18 and 41% per women and a cycle fecundity rate of 3.4 and 8.8% after IUI and TI, respectively; this difference was not significant. As far as is known, a direct head-to-head comparison of CC/IUI and CC/TI as first-line treatment in women with PCOS has not been undertaken. The objective of this randomized controlled trial was to compare the efficacy of CC/IUI and CC/TI as first-line treatment for anovulatory infertility associated with PCOS. Material and methods A total of 188 women with PCOS attending the Outpatient Clinic in Mansoura University Hospitals, Mansoura University, Egypt, and a private practice setting from May 2007 to February 2010 were studied. The diagnosis of PCOS was based on the revised 2003 Rotterdam consensus on diagnostic criteria and long-term health risks related to PCOS (22). All women had patent Fallopian tubes as confirmed by hysterosalpingography and their partners had normal semen analysis parameters according to the modified criteria of World Health Organization (1999) (23). At study entry, all women had the following basal hormonal assays (Day 2 or 3 of spontaneous or progesterone-induced menstruation): follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), prolactin, 17-hydroxyprogesterone (17-OHP), total testosterone and sex hormone-binding globulin (SHBG) measured by specific ELISA (DIMA kit, Germany). Fasting serum insulin (ECLIA method, ElecCys, Germany) and glucose levels (glucose oxidase method, Biomérieux, France) were also performed. All women had normal serum prolactin, TSH and 17-OHP. Exclusion criteria were other causes of infertility, age <18 years or >38 years, BMI >30, women with a previous pregnancy and women who had received ovarian stimulation drugs such as CC, metformin, gonadotrophin or other hormonal drugs. Women who intended to start a diet or a specific program of physical activity were also excluded. All women were instructed to maintain their usual lifestyle and eating habits during the study. The study was approved by the Mansoura University Hospital Research Ethics Committee and all participants gave informed consent before inclusion in the trial. The study protocol was registered at the Australian New Zealand Clinical Trial Registry (ACTRN ) in accordance with the Declaration of Helsinki and the recommendations of the Committee of Medical Journal Editors. The trial is reported and analyzed following the CONSORT criteria. Women were randomized according to a computergenerated random numeric table prepared by an independent statistician with concealment of treatment allocation using sealed opaque envelopes that were given to a third party (nurse) who assigned women to the study arms, group A (CC/IUI) or group B (CC/TI). Outcome assessors were blinded to the treatment groups. All women received CC (Clomid R ; Global Napi Pharmaceuticals, Cairo, Egypt) using a classical incremental regimen. CCwasadministeredfor5daysstartingfromDay3ofspontaneous or induced menstruation using a starting dose of 50 mg daily. If ovulation did not occur, the dose was increased by 50 mg in successive cycles until ovulation was achieved or up to a maximal dose of 150 mg daily. All women were monitored by transvaginal ultrasound for mean follicular diameter and endometrial thickness on days 10, 12 and 14 of the cycle. hcg (a total of IU intramuscular Choriomon; IBSA, Lugano, Switzerland) was given when one follicle measuring at least 18 mm was found. Both IUI and TI were performed hours after hcg injection and all women were requested to avoid intercourse for 4 days before the expected time of ovulation until either IUI or TI were indicated. All couples underwent a maximum of three cycles of treatment. Serum E2 (pg/ml) was measured at the time of hcg injection by the ECLIA method and serum progesterone (ng/ml) was measured on days by the ECLIA method. Ovulation was confirmed when the serum progesterone level was 5 ng/ml. Biochemical pregnancy was considered to have occurred when serum β-hcg was 50 miu/ml or more 2 weeks after either IUI or TI. A clinical pregnancy was confirmed by sonographic evidence for an intrauterine gestational sac at 6 weeks gestation. All pregnant women were followed up to obtain miscarriage and live birth rates. The latter were 345

3 Insemination in polycystic ovary syndrome H. Abu Hashim et al. defined as the percentage of women who had a live baby per total number of women. Semen specimens were collected by masturbation. After liquefaction, the ejaculate was placed in 10 ml of warmed (37 C) Ham s F-10 (Sigma, Aldrich Chemie, GmbH, Steinheim, Germany) and centrifuged at g for 5 minutes. The supernatant was then discarded and the pellet resuspended in approximately 500 μl. A single intrauterine insemination was performed using a flexible intrauterine cannula (Gynetics Medical Products N.V. Harmont, Achel, Belgium). The cervix was exposed with a bivalve speculum, the mucus was removed with a cotton swab, and the tip of the catheter was gently introduced into the uterus until it lay about 0.5cm from the top of the uterine cavity in the fundal region. The in vitro-prepared sperm was expelled gently and the catheter subsequently withdrawn. Women remained supine for 10 minutes after the procedure. Statistical analysis The primary outcome measure was the clinical pregnancy rate per cycle. Secondary outcome measures were the number of growing and mature follicles, serum E2 (pg/ml) and endometrial thickness (mm) at the time of hcg administration, ovulation rate, serum progesterone (ng/ml) in the luteal phase, miscarriage and live birth rates. Sample size was determined based on an expected clinical pregnancy rate of 5.3% per cycle in the CC group (7) and 12.6% per CC/IUI cycle (19). A total of 500 cycles (250 for each group) were required for a statistical power of 80% using a two-tailed chi-squared test with a 5% significance level (type I error). Estimating that each couple would require three cycles to achieve pregnancy, the number of couples required for the treatment was approximately 85 in each group. Data obtained were analyzed using the statistical package for social sciences (SPSS, Chicago, IL, USA) software version 15.0 for Windows. Means were compared using the unpaired Student s t-test, and proportions were compared using the chi-squared test. A p-value of <0.05 was considered significant. Results A total of 525 cycles were studied in 188 women; 259 cycles in 93 women in group A (CC/IUI) and 266 cycles in 95 women in group B (CC/TI). There were no differences between the two groups as regards age, duration of infertility, anthropometric variables, clinical manifestations, hormonal profiles or ultrasound findings of PCOS (Table 1). Figure 1 shows the flow of participants in the trial. Clinical and reproductive outcomes are presented in Table 2. There were no differences between the two groups as regards ovulation rate per cycle or per woman (52.1 vs. 51.5% and 77.4 vs. 76.8%, respectively). There were no differences between the groups regarding the total number of Table 1. Patient characteristics. Group A Group B p-value (CC/IUI) (CC/TI) (n=93) (n=95) Age (years) 26.3 ± ± Duration of infertility (years) 2.2 ± ± BMI (kg/m 2 ) 25.1 ± ± Waist-to-hip ratio 0.8 ± ± Menstrual cycle Oligomenorrhea 87(93.5%) 88(92.6%) 0.43 Amenorrhea 6(6.5%) 7(7.4%) 0.61 Hyperandrogenism 42(45.1%) 39(41%) 0.74 LH (miu/ml) 12.8 ± ± FSH (miu/ml) 5.7 ± ± LH/FSH ratio 2.6 ± ± Fasting glucose (mg/dl) 90.8 ± ± Fasting insulin (μu/ml) 10.9 ± ± Fasting glucose/insulin ratio 7.6 ± ± Ovarian volume (ml) 11.2 ± ± CC, clomiphene citrate; IUI, intrauterine insemination; TI, timed vaginal intercourse; BMI, body mass index. Values are mean ±SD or numbers (percentages) of women. None of the differences was statistically significant (p>0.05). follicles, the number of follicles 14mm and 18mm during stimulation. There were no differences in either pretreatment or endometrial thickness at the time of hcg administration betweenthe groups (7.7±0.4 vs. 7.5±0.6mm). There were no differences between the groups with regard to the duration of stimulation, i.e. the mean hcg day of administration, serum E2 and progesterone concentrations. There were no differences between the two groups as regards the clinical pregnancy rate per cycle or per woman (8.49 vs. 7.89% and 23.6 vs. 22.1%, respectively). In cycles in which ovulation occurred, the pregnancy rate per cycle was 16.3% with CC/IUI and 15.3% with CC/TI; this difference was not significant (Table 2). Two twin pregnancies occurred in each group. No ectopic, higher-order pregnancies or cases of ovarian hyperstimulation syndrome occurred in either group. There were no differences with regard to miscarriage or live birth rates among women in the two groups (18.1 vs. 19% and vs %, respectively). Discussion Pharmacologically, CC is a racemic mixture of two distinct stereoisomers, enclomiphene and zuclomiphene, with different properties. Levels of enclomiphene rise rapidly after administration and fall to undetectable concentrations after a few days. In contrast, zuclomiphene is cleared far more slowly; it remains detectable in the circulation for more than a month after treatment and may accumulate over consecutivecyclesoftreatment,butthereisnoevidenceofany important clinical consequences (24). It is frustrating that 346

4 H. Abu Hashim et al. Insemination in polycystic ovary syndrome Assessed for eligibility (n=262) Enrollment Excluded (n=74) Not meeting inclusion criteria (n=49) Refused to participate (n=25) Randomized (n=188) Allocation Allocated to CC+IUI (n=93) Received allocated intervention (n=93) Did not receive allocated intervention; give reasons Allocated to CC+ TI (n=95) Received allocated intervention (n=95) Did not receive allocated intervention; give reasons Follow-up Lost to follow-up; Discontinued intervention; Lost to follow-up; Discontinued intervention; Figure 1. CONSORT flowchart. Analysis Analyzed (n=259 cycles) Excluded from analysis; Analyzed (n=266 cycles) Excluded from analysis; the restoration of ovulation by CC does not produce a much higher pregnancy rate, as only 50% of those who ovulate will conceive (12). This may be explained by the peripheral antiestrogenic effects of CC at the level of the endometrium and cervical mucus (8 12). Theoretically speaking, performing IUI could overcome the depression of the cervical mucus. In the present study, a clinical pregnancy rate per cycle of 8.49% was found in the CC/IUI group. Custers et al. (25) reported a 5 7% pregnancy rate per cycle following CC/IUI, even after seven cycles. So, performing IUI did not translate into significantly higher clinical pregnancy rates. This might be related to reduced endometrial thickness at the time of hcg administration (7.7±0.4 mm). Our findings match those reported by other investigators who found thinner endometrial thickness with the use of CC when measured on late proliferative days (9 12,26). In some women, CC blocks endometrial estrogen receptors and suppresses pinopode formation, both essential for implantation, to such an extent that implantation may be impeded. This suppression of endometrial proliferation is a non-dose-dependent, idiosyncratic action that recurs in repeated cycles in the same woman. It indicates a poor prognosis for conception if the endometrial thickness on ultrasound scanning does not reach 8mm at ovulation (12,27). The duration of infertility of 2.2±0.1 years may be another factor explaining the reduced pregnancy rate in the IUI group in our study. Recently, it was reported that IUI performed in stimulated cycles was effective only in women with more than 3 years of infertility, but this is associated with a significantly higher rate of higher-order multiple births (16). In this study, a single IUI was carried out hours after hcg injection and the semen was prepared utilizing a swimup technique, isolating the most motile spermatozoa prior to insemination. A systematic review and a recent meta-analysis reported that double IUI offers no clear benefit for the overall clinical pregnancy rate in stimulated cycles for subfertile couples (28,29). Also, a recent Cochrane review showed no significant differences between the different timing methods 347

5 Insemination in polycystic ovary syndrome H. Abu Hashim et al. Table 2. Outcome in CC/IUI and CC/TI groups. Group A Group B p-value (CC/IUI) (CC/TI) (n=93) (n=95) Number of cycles Total number of 4.2 ± ± follicles Number of follicles 2.4 ± ± mm Number of follicles 1.8 ± ± mm Pretreatment 5.6 ± ± endometrial thickness (mm) Endometrial thickness 7.7 ± ± at hcg day Serum E2 at hcg day ± ± (pg/ml) Serum progesterone 8.7 ± ± (ng/ml) Duration of 12.7 ± ± stimulation (days) Ovulation/cycle 135/259 (52.1%) 137/266 (51.5%) 0.64 Ovulation/woman 72/93 (77.4%) 73/95 (76.8%) 0.57 Clinical pregnancy/ 22/259 (8.49%) 21/266 (7.89%) 0.26 cycle Clinical pregnancy/ 22/135 (16.3%) 21/137 (15.3%) 0.28 ovulatory cycle Clinical pregnancy/ 22/93 (23.6%) 21/95 (22.1%) 0.33 woman No. of twin 2/22 (9%) 2/21 (9.5%) 0.46 pregnancies (%) Miscarriage/ 4/22 (18.1%) 4/21 (19%) 0.31 pregnancy Live birth rate 18/93 (19.35%) 17/95 (17.89%) 0.33 CC, clomiphene citrate; IUI, intrauterine insemination; TI, timed vaginal intercourse. Values are mean ±SD or numbers (percentages). None of the differences was statistically significant (p>0.05). for IUI, including hcg administration (urinary or recombinant), detection of LH surge and GnRH agonist administration (30). Furthermore, there is insufficient evidence for recommending any specific semen preparation technique (31). Also, for normal semen samples, it is still unclear whether there is any advantage in isolating the most motile spermatozoa prior to insemination or whether similar results can be obtained using the whole population of spermatozoa in the sample (16). In our study, two twin pregnancies (9%), an 18.1% miscarriage rate and a 19.35% live birth rate occurred in the CC/IUI group. This is in line with a multiple pregnancy rate of 8 13% reported with CC, the vast majority being twin pregnancies, and miscarriage and live birth rates of 20.4 and 25%, respectively (27). The cost of treatment is another issue, especially in developing communities, where economic aspects of therapy are important. The addition of IUI increased the cost of treatment, required more organizational effort for the medical team, and can sometimes be unacceptable to some couples because of manipulation of the spermatozoa. TI is the usual control treatment in trials of IUI. This choice appears to be founded on a belief that a credible comparison of IUI with intercourse requires that intercourse should be timed in a manner similar to the timing of IUI (20). Actually, there are no trials comparing TI with expectant management, i.e. ordinary intercourse which allows couples to make their own choices with respect to the timing and frequency of intercourse. Snick et al. (20) compared IUI treatment effects in couples with unexplained infertility in trials where TI was the alternative and those with expectant management controls. The average difference in pregnancy rate between IUI and controls was 6.1% in TI trials and 3.9% in expectant management trials. The adjusted indirect estimate of the difference between the types of control groups was 2.8% and the difference between trials with TI and expectant management controls was not significant. They concluded that the additional benefit accruing to IUI from using TI as the control was not significant, but the results are consistent with the possibility that pregnancy may be less likely in TI controls than in expectant management controls. This finding may become of concern in couples with unexplained infertility, in whom the fertile window may be shortened (32). However, this may not be applicable in women with PCOS where, due to anovulation, there are no precise estimates of variation in length of the fertile window. Consequently, treatment consists of CC for ovulation induction, and not superovulation, as in case of unexplained infertility. There are some concerns regarding our study. First, the sample size was calculated using the clinical pregnancy rate as the primary outcome, although live birth rate would be the ideal primary outcome. The comparison between two treatment arms showed no significant benefit of CC/IUI over CC/TI in terms of live birth rate. A post-study power and sample size for live birth rate were calculated using power analysis and sample size software (PASS 2008, NCSS, USA). Considering the present data, at least 280 women per group (560 total) are needed to detect a 10% difference between both groups regarding the live birth rate in women with PCOS with a power of 80%. Moreover, considering our restricted inclusion/exclusion criteria, which imply an exclusion of 28.2% of the initially screened women, more than 720 women should be screened. This would necessitate multicentre trial recruitment. Secondly, one could argue that it would be relevant to have a third group receiving CC without IUI and TI. If that alternativewereaseffectiveasthetwointhestudy,thehcg step would be unnecessary. However, this conclusion should be regarded with caution as many confounders will evolve 348

6 H. Abu Hashim et al. Insemination in polycystic ovary syndrome in relation to frequency of intercourse and the expected time interval between intercourse and ovulation. When surveying women using non-hormonal contraception, Wilcox et al. (33) found that the frequency of spontaneous intercourse increased during the follicular phase of the cycle, peaking at the time of ovulation, and declining abruptly thereafter. Does the same pattern exist in women with PCOS who receive CC therapy for treatment of their anovulatory infertility? Thirdly, the number of growing follicles, serum E2 and endometrial thickness may be regarded as more descriptive information, as no difference was expected between the two groups. However, they are important prognostic factors in IUI treatment and reporting them as secondary outcome measures is recommended (34 36). In conclusion, this trial suggests that ovulation induction with CC and TI is as effective as with CC and IUI for achieving pregnancy in women with PCOS and could represent the initial treatment option, being less invasive and less expensive compared to IUI. Funding No specific funding. References 1. Saleh AM, Khalil HS. Review of nonsurgical and surgical treatment and the role of insulin-sensitizing agents in the management of infertile women with polycystic ovary syndrome. Acta Obstet Gynecol Scand. 2004;83: Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril. 2008;89: Brown J, Farquhar C, Beck J, Boothroyd C, Hughes E. Clomiphene and anti-oestrogens for ovulation induction in PCOS. Cochrane Database Syst Rev. 2009;(4):CD Gysler M, March CM, Mishell DR, Bailey EJ. A decade s experience with an individualized clomiphene treatment regimen including its effects on the postcoital test. Fertil. Steril. 1982;37: ACOG Committee on Practice Bulletins-Gynecology. Management of infertility caused by ovulatory dysfunction. ACOG Practice Bulletin No. 34. Obstet Gynecol. 2002;99: Lobo RA. Choice of treatment for women with polycystic ovary syndrome. Fertil Steril. 2006;86(Suppl 1):S Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, et al. Cooperative Multicenter Reproductive Medicine Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med. 2007;356: Randall JM, Templeton A. Cervical mucus score and in vitro sperm mucus interaction in spontaneous and CC citrate cycles. Fertil Steril 1991;56: Dickey RP, Olar TT, Taylor SN, Curole DN, Matulich EM. Relationship of endometrial thickness and pattern to fecundity in ovulation induction cycles: effect of clomiphene citrate alone and with human menopausal gonadotropin. Fertil Steril 1993;59: Opsahl MS, Robins ED, O Connor DM, Scott RT, Fritz MA. Characteristics of gonadotropin response, follicular development, and endometrial growth and maturation across consecutive cycles of clomiphene citrate treatment. Fertil Steril 1996;66: Nakamura Y, Ono M, Yoshida Y, Sugino N, Ueda K, Kato H. Effects of CC on the endometrial thickness and echogenic pattern of the endometrium. Fertil Steril 1997;67(2): Homburg R. Clomiphene citrate-end of an era? A mini-review. Hum Reprod. 2005;20: Cantineau AE, Cohlen BJ, Heineman MJ. Ovarian stimulation protocols (anti-oestrogens, gonadotrophins with and without GnRH agonists/antagonists) for intrauterine insemination (IUI) in women with subfertility. Cochrane Database Syst Rev. 2007;(2):CD Bensdorp AJ, Cohlen BJ, Heineman MJ, Vandekerckhove P. Intra-uterine insemination for male subfertility. Cochrane Database Syst Rev. 2007;(4):CD Verhulst SM, Cohlen BJ, Hughes E, Te Velde E, Heineman MJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev. 2006;(4):CD Aboulghar M, Baird DT, Collins J, Evers JL, Fauser BC, Lambalk CB, et al. Intrauterine insemination. ESHRE Capri Workshop Group. Hum Reprod Update. 2009;15: Abdelkader AM, Yeh J. The potential use of intrauterine insemination as a basic option for infertility: a review for technology-limited medical settings. Obstet Gynecol Int. 2009; Andersen AN, Goossens V, Gianaroli L, Felberbaum R, de Mouzon J, Nygren KG. Assisted reproductive technology in Europe, Results generated from European registers by ESHRE. Hum Reprod. 2007;22: Kalu E, Thum MY, Abdalla H. Intrauterine insemination in natural cycle may give better results in older women. J Assist Reprod Genet. 2007;24: Snick HK, Collins JA, Evers JL. What is the most valid comparison treatment in trials of intrauterine insemination, timed or uninfluenced intercourse? A systematic review and meta-analysis of indirect evidence. Hum Reprod. 2008;23: Agarwal S, Mittal S. A randomised prospective trial of intrauterine insemination versus timed intercourse in superovulated cycles with clomiphene. Ind J Med Res. 2004;120: The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81:

7 Insemination in polycystic ovary syndrome H. Abu Hashim et al. 23. World Health Organization. WHO Laboratory Manual for the Examination of Human Semen and Sperm-Cervical Mucus Interactions, 4th edn. Cambridge: Cambridge University Press, Practice Committee of the American Society for Reproductive Medicine. Use of clomiphene citrate in women. Fertil Steril. 2006;86(Suppl 1):S Custers IM, Steures P, Hompes P, Flierman P, van Kasteren Y, van Dop PA, et al. Intrauterine insemination: how many cycles should we perform? Hum Reprod. 2008;23: Al-Inany H, Azab H, El-Khayat W, Nada A, El-Khattan E, Abou-Setta AM. The effectiveness of clomiphene citrate in LH surge suppression in women undergoing IUI: a randomized controlled trial. Fertil Steril. 2010;94: Homburg R. Polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2008;22: Cantineau AEP, Heineman MJ, Cohlen BJ. Single versus double intrauterine insemination (IUI) in stimulated cycles for subfertile couples. Cochrane Database Syst Rev. 2003;(1):CD Polyzos NP, Tzioras S, Mauri D, Tatsioni A. Double versus single intrauterine insemination for unexplained infertility: a meta-analysis of randomized trials. Fertil Steril. 2010;94: Cantineau AE, Janssen MJ, Cohlen BJ. Synchronised approach for intrauterine insemination in subfertile couples. Cochrane Database Syst Rev. 2010;(4):CD Boomsma CM, Heineman MJ, Cohlen BJ, Farquhar C. Semen preparation techniques for intrauterine insemination. Cochrane Database Syst Rev. 2007;(4):CD Keulers MJ, Hamilton CJ, Franx A, Evers JLH, Bots RSGM. The length of the fertile window is associated with the chance of spontaneously conceiving an ongoing pregnancy in subfertile couples. Hum Reprod. 2007;22: Wilcox AJ, Baird DD, Dunson DB, McConnaughey DR, Kesner JS, Weinberg CR. On the frequency of intercourse around ovulation: Evidence for biological influences. Hum Reprod. 2004;19: Ghosh C, Buck G, Priore R, Wacktawski-Wende J, Severino M. Follicular response and pregnancy among infertile women undergoing ovulation induction and intrauterine insemination. Fertil Steril. 2003;80: Esmailzadeh S, Faramarzi M. Endometrial thickness and pregnancy outcome after intrauterine insemination. Fertil Steril. 2007;88: Merviel P, Heraud MH, Grenier N, Lourdel E, Sanguinet P, Copin H. Predictive factors for pregnancy after intrauterine insemination (IUI): an analysis of 1038 cycles and a review of the literature. Fertil Steril. 2010;93: