Scholarly Series No.1: Timed Intercourse vs IUI in PCOS Patients

Over the past several infertility decisions we've have to make recently, my nerdy side has kicked in full-force and I have found myself turning to primary-source research articles. It's been very helpful to read the same scholarly journals that the professionals are reading and, given my background in research and statistics, I can actually understand most of it.

Because nerdism should be shared, I've decided to start a new series of posts, hereby known as the Scholarly Series, in which I will discuss an original journal articles. I will try to choose recent papers, likely ones that are relevant to my current situation or ones that I just find interesting. I may include some of the classics as well. In preparation for this, I've actually found several papers that I can't wait to share with people! So without further delay, here is the inaugural Scholarly Series:

Wisner, A., Shalom-Paz, E., Reinblatt, S.L., Holzer, H., and Tulandi, T. (2012). Controlled Ovarian Hyperstimulation in Women With Polycystic Ovarian Syndrome With or Without Intrauterine Insemination. Gynecological Endocrinology, 28 (7), 502 - 504.

Summary

This study evaluated the value of IUI among couples with PCOS and a normal semen analysis. It was a retrospective design, utilizing medical records review. The authors evaluated records of 156 women with PCOS treated with either Clomid, Letrozole, or gonadotropins in 2009 and 2010 and only looked at cycles that resulted in actual ovulation.  Women were given oral medications for three months and then moved on to injectables if not conceiving after this time. IUI was decided based on the physicians preference and was performed 36 hours after the HCG injection. If the couples used Time Intercourse (TIC) instead, they were instructed to perform TIC on the day of the HCG shot and then the following two days. The primary outcome was pregnancy, defines as having a gestation sac and fetal heart activity.

Of the total participants, 86 patients underwent a total of 145 cycles of IUI and the other 70 patients underwent 114 cycles of timed intercourse. Each couple was included in only group. The two groups were relatively similar in regards to the woman's age, BMI, number of dominant follicles, endometrial thickness, and semen concentration/motility/morphology. The results found that there were no significant differences between the Timed Intercourse group (17.5%) and the IUI group (16.6%) overall. In fact, the only variable that appeared to make a difference in pregnancy rates were whether patients used gonadotropins (38.8% for TIC couples and 25.7% for IUI couples) versus oral medications (14.1% for TIC couples and 7.5% for IUI couples). The authors concluded that IUI does not increase pregnancy rates compared with timed intercourse for this population (i.e. normal SA and PCOS).

Review

The study utiized a retrospective design, which isn't as strong as a prospective, randomized control trial because you are unable to control any of the variables or randomly assign participants, which could indicate that there is selection bias in the sample. Also, the study was based out of only site in Quebec, so it's not necessarily generalizable to other locations or populations. It also rubbed me the wrong way that the decision of IUI vs TIC was based on physician preference and did not mention patient preference, but I supposed you also have to consider the audience.

Despite this, the sample size was large and the results were very interesting to me. I previously assumed that IUI automatically added to your chances of success, but then with this article and a few others I came across, I realized that this is not always the case. In fact, one of the current hot topics in reproductive endocrinology is whether IUIs are a valuable tool at all. Based on this research and some others, C and I decided to forgo IUI for this cycle and instead go the Timed Intercourse route. The decision was made easier by the fact that we're still pretty early in the game, as I know it will become much more complicated when/if the decision shifts to trying IUI vs jumping straight to IVF. But alas, that will be the topic for the next Scholarly Series post.