Monday was IUI day. After an opening keynote session which saw standing room only in a hall with 3000 seats, there was also a full house for an early free communication session on IUI in unexplained infertility. Both the opening two reports of the session made a strong case for IUI itself, and in contradiction to the recommendations of NICE, which, on the basis of limited evidence, had recommended in 2013 two years of wait-and-see to be followed by IVF. Indeed, said Cindy Farquhar, this controversial recommendation was the very basis of her New Zealand trial, which compared three cycles of IUI (with clomiphene citrate) with three cycles of expectant management on cumulative LBRs. Dr Farquhar, from the University of Auckland, said that the NICE recommendations were based on just two trials in unexplained infertility, one of which included IUI without stimulation. Results of the study, which had randomised 201 patients with unexplained infertility to IUI or expectant management, showed that the former was associated with a three-fold greater live birth rate than the latter (31% vs 9%). ‘IUI with clomiphene,’ said Dr Farquhar with a little understatement, ‘may be offered to couples with unexplained infertility as a safe and effective treatment.’
This too was the conclusion reached by another RCT, this from the Netherlands, whose presenter, Dr Monique Mochtar from the Amsterdam Medical Centre, even went so far as to recommend IUI with clomiphene stimulation as first choice in unexplained infertility – less invasive, less expensive and just as effective as FSH.
The study, performed in 24 fertility centres in the Netherlands, randomised 369 women to IUI with FSH and 369 women to IUI with clomiphene. Results showed that 31% (113 women) had an ongoing pregnancy following IUI-FSH and 26% (97 women) had an ongoing pregnancy following IUI-CC. Results also showed that five women (1%) had a multiple pregnancy following IUI-FSH and eight (2%) had a multiple pregnancy following IUI-CC – again, a statistically non-significant difference.
In an interview with me after her presentation Dr Mochtar suggested that the NICE guidelines might well need revision following publication of these two trials. She had no doubt that in her recommendations treatment should start with IUI stimulated with clomiphene. However, it should be noted that 48 of the 210 ongoing pregnancies (23%) in the Dutch study were achieved by natural conception. This too is in line with the natural conception rate reported from other trials, thus suggesting that ‘expectant management’ might not be such a hopeless alternative. As one UK IVF veteran said, couples are usually better off just ‘getting on with it’.
Simon Brown, Editor of Focus on Reproduction