Published 29 October 2009, doi:10.1136/bmj.b4274
Cite this as: BMJ 2009;339:b4274

Editorials

Supine positioning after intrauterine insemination

Shows promise in increasing pregnancy rates, but further studies are needed

In the United Kingdom, intrauterine insemination is the mainstay of fertility treatment carried out before couples embark on in vitro fertilisation. It is recommended by the National Institute for Health and Clinical Excellence (NICE) and by a recent international workshop¹ for couples with mild male factor infertility, unexplained infertility, and mild endometriosis.²

Intrauterine insemination is attractive to couples who want minimal drug treatment, low costs, and fertilisation in the fallopian tube, as in natural conception. Many people who have religious or moral objections to in vitro fertilisation find intrauterine insemination acceptable, and the procedure is often provided in small local clinics that cannot support more costly and complex treatments. However, the approach to intrauterine insemination varies, and it is unclear which approach is best.^{1 3} Success rates vary from 5% to 70%.⁴ In the linked randomised controlled study (doi:10.1136/bmj.b4080), Custers and colleagues compared the effectiveness of 15 minutes of immobilisation, during which women stayed in a supine position, with immediate mobilisation after intrauterine insemination.⁵

Intrauterine insemination has three steps. Firstly, the woman receives gentle ovarian stimulation with oral clomifene citrate or injectable follicle stimulating hormone or no stimulation at all in the natural cycle approach. Ovarian follicle growth is monitored by ultrasound, and women with too many mature follicles have their treatment cancelled or they undergo in vitro fertilisation, to minimise the risk of multiple pregnancy. Secondly, when the lead follicle diameter reaches a point deemed to signify follicle and oocyte maturity, a single injection of human chorionic gonadotrophin is given to allow ovulation to be timed. Thirdly, about 36 hours later a prepared sample of the motile fraction of sperm is placed into the uterine cavity using a Cusco’s speculum and a fine flexible transfer catheter. Pregnancy rates per cycle do not approach those of in vitro fertilisation (in the UK 29% for the first cycle of in vitro fertilisation versus 12% for intrauterine insemination in women under 35), but the simplicity and low cost of intrauterine insemination allow for several cycles to be carried out quickly with acceptable cumulative conception rates. This technique has recently joined the list of procedures licensed by Human Fertilisation and Embryology Authority in the UK, and it is one of the most widely used forms of assisted reproductive technology.⁶

Three randomised trials have assessed various aspects of intrauterine insemination in recent years—the use of gonadotrophin stimulation compared with clomifene citrate,⁷ single versus double insemination,⁸ and whether intrauterine insemination is superior to expectant management in unexplained infertility.⁹ However, little attention has been paid to the mechanics of the procedure, so specialists have had to rely on evidence from case series and other less rigorous forms of evidence to make rational decisions on treatment.

Custers and colleagues found that of the 391 couples who were randomised, the ongoing pregnancy rate per couple was significantly higher in women who were immobilised than in those who were immediately mobilised (27% v 18%; relative risk 1.5, 95% confidence interval 1.1 to 2.2). Live birth rates were 27% and 17%, respectively (1.6, 1.1 to 2.4).

Their findings agree with the intuitive idea that lying with a "feet up" tilt for a few minutes after insemination, either after intercourse or intrauterine insemination, allows the sperm to ascend into the uterine cavity, before standing up brings the negative influences of gravity into play. Such postcoital positioning was advocated in the United States many years ago but did not seem to improve conception rates after sex.

The study can be criticised. Overall pregnancy rates are lower than is seen in many centres that do not use immobilisation, and the use of ovarian stimulation varied considerably between centres, with about a third of women receiving no stimulatory drugs and others receiving either clomifene or follicle stimulating hormone. Although the authors make a virtue of the heterogeneity, suggesting that it more closely mirrors clinical practice, we are not told whether allocation to stimulation or no stimulation made a difference to outcome. Most fertility clinics rely on follicle stimulating hormone stimulation for intrauterine insemination because pregnancy rates without stimulation are low.

What are the implications of these results for practice? A busy assisted reproduction centre will carry out several intrauterine inseminations over the course of an hour. A 15 minute delay would affect clinic turnover, although with planning this would not be insurmountable. The results suggest that units should carry out their own evaluation of immobilisation versus immediate mobilisation after intrauterine insemination, to test the hypothesis in the "real world." If successful, more couples could be spared the rigorous and costly process of in vitro fertilisation. Future trials should assess the effect of different durations of immobilisation.

Cite this as: BMJ 2009;339:b4274

¹ Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2SF

Research, doi:10.1136/bmj.b4080

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. ESHRE Capri Workshop Group1. Intrauterine insemination. Hum Reprod Update 2009;15:265-77.[Abstract/Free Full Text]
2. National Institute for Health and Clinical Excellence. Fertility: assessment and treatment for people with fertility problems. 2004. www.nice.org.uk/CG011.
3. Rawal N, Drakeley A, Haddad N. Intrauterine insemination practice in the UK. J Obstet Gynaecol 2008;28:738-41.[CrossRef][Web of Science][Medline]
4. Allen NC, Herbert CM III, Maxson WS, Rogers BJ, Diamond MP, Wentz AC. Intrauterine insemination: a critical review. Fertil Steril 1985;44:569-80.[Web of Science][Medline]
5. Custers IM, Flierman PA, Maas P, Cox T, Van Dessel TJHM, Gerards MH, et al. Immobilisation versus immediate mobilisation after intrauterine insemination: randomised controlled trial. BMJ 2009;339:b4080.[Abstract/Free Full Text]
6. Andersen AN, Goossens V, Ferraretti AP, Bhattacharya S, Felberbaum R, de Mouzon J, et al; European IVF-monitoring (EIM) Consortium; European Society of Human Reproduction and Embryology (ESHRE). Assisted reproductive technology in Europe, 2004: results generated from European registers by ESHRE. Hum Reprod 2008;23:756-71.[Abstract/Free Full Text]
7. Cantineau AE, Cohlen BJ, Heineman MJ. Ovarian stimulation protocols (anti-oestrogens, gonadotrophins with and without GnRH agonists/insemination (IUI) in the treatment of unexplained infertility: a prospective randomized study. Hum Reprod 1993;8:890-4.[Abstract/Free Full Text]
8. Polyzos NP, Tzioras S, Mauri D, Tatsioni A. Double versus single intrauterine insemination for unexplained infertility: a meta-analysis of randomized trials. Fertil Steril 2009 Online Aug 7.
9. Bhattacharya S, Harrild K, Mollison J, Wordsworth S, Tay C, Harrold A, et al. Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial. BMJ 2008;337:a716.[Abstract/Free Full Text]

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