Intrauterine Insemination orIn-VitroFertilisation in Idiopathic Subfertility and Male Subfertilitycolon; A Randomised Trial and Cost-Effectiveness Analysis

摘要

Couples who are subfertile for unknown reasons or because of male factors spontaneously conceive at an estimated rate of about 2 percent per cycle. Counseling of these couples has proved difficult because of a paucity of high-quality comparative studies. This prospective, randomized trial randomly assigned 258 couples with idiopathic or male subfertility to receive a maximum of six cycles of intrauterine insemination (IUI) in the spontaneous cycle, IUI after mild ovarian hyperstimulation, orin vitrofertilization (IVF). The primary end point was pregnancy resulting in a live birth. The couples had had idiopathic subfertility for at least 3 years or male subfertility for 1 year or longer. IUI alone was performed 20 to 30 hours after the endogenous LH surge was detected. Mild hyperstimulation was produced using a low dose of FSH. IVF utilized controlled ovarian hyperstimulation by a gonadotropin-releasing hormone agonist and human menopausal gonadotropin or FSH. Brief stimulation was used in women older than 38 years.Eighteen couples conceived between treatment cycles, for spontaneous delivery rates of 1.25 percent in cases of idiopathic subfertility and 0.8 percent in cases of male subfertility. Treatment led to 89 pregnancies and the delivery of 107 children. Delivery rates were 31 percent with IUI alone, 37 percent with IUI and stimulation, and 38 percent with IVF. Multiple pregnancies accounted for 29 percent of viable pregnancies in the IUI/stimulation group and 21 percent in the IVF group. A single monozygotic twin pregnancy occurred after IUI alone. Two women having IUI with stimulation developed mild ovarian hyperstimulation syndrome. Three in the IVF group had severe hyperstimulation syndrome. The cost of a single IVF treatment cycle was 3.5 times higher than one IUI treatment in a stimulated cycle and 5 times higher than IUI in a spontaneous cycle. IUI was most cost-effective for all diagnostic groups and all age groups. The two IUI treatments did not differ significantly in this respect.IVF may tend to be more effective on a per-cycle basis but does not yield higher cumulative pregnancy rates after six treatment cycles. IUI in a spontaneous cycle is safer and more convenient, and its expense is less than that of the other methods. The investigators believe that IUI in a spontaneous cycle should be the first measure in cases of idiopathic or male subfertility.Lancet 2000;355:13–18