Intra-uterine insemination versus timed intercourse or expectant management for cervical hostility in subfertile couples

Abstract

Background: The postcoital test has poor diagnostic and prognostic characteristics. Nevertheless, some physicians believe it can identify scanty or abnormal mucus that might impair fertility. One way to avoid 'hostile' cervical mucus is intrauterine insemination. With this technique, the physician injects sperm directly into the uterine cavity through a small catheter passed through the cervix; the theory is to bypass the "hostile" cervical mucus. Although most gynaecological societies do not endorse use of intrauterine insemination for hostile cervical mucus, some physicians consider it an effective treatment for women with infertility thought due to cervical mucus problems. Objectives: The aim of this review was to determine the effectiveness of intrauterine insemination with or without ovarian stimulation in women with cervical hostility who failed to conceive. Search methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 3, 2008, MEDLINE (1966 to August 2008), EMBASE (1980 to August 2008), POPLINE (to August 2008) and LILACS (to August 2008). In addition, we contacted experts and searched the reference list of relevant articles and book chapters. Selection criteria: We included randomised and quasi-randomized controlled trials comparing intrauterine insemination with intercourse timed at the presumed fertile period or expectant management. Participants were women with cervical hostility who failed to conceive for at least one year. Data collection and analysis: We assessed the titles and abstracts of 396 publications and two reviewers independently abstracted data on methods and results from five studies identified for inclusion. The main outcome is pregnancy rate per couple. Main results: We did not pool the outcomes of the included six studies in a meta-analysis due to the methodological quality of the trials and variations in the patient characteristics and interventions. Narrative summaries of the outcomes are provided. Each study was too small for a clinically relevant conclusion. Only one of the studies provided information on important outcomes such as spontaneous abortion, multiple pregnancies, but none of studies reported on the occurrence of e.g. ovarian hyperstimulation syndrome. Authors' conclusions: There is no evidence from the published studies that intrauterine insemination is an effective treatment for cervical hostility. Given the poor diagnostic and prognostic properties of the postcoital test and the observation that the test has no benefit on pregnancy rates, intrauterine insemination (with or without ovarian stimulation) is unlikely to be a useful treatment for putative problems identified by postcoital testing.