Intrauterine insemination (IUI) as a first-line treatment in developing countries and methodological aspects that might influence IUI success

It is generally accepted that intrauterine insemination (IUI) should be preferred to more invasive and expensive techniques of assisted reproduction and be offered as a first-choice treatment in cases of unexplained and moderate male factor subfertility. Scientific validation of this strategy is rather difficult because literature is rather confusing and not conclusive. IUI is proven easier to perform, less invasive and less expensive than other methods of assisted reproduction. Effectivity has been documented in controlled studies under the condition that the inseminating motile count exceeds more than 1 million motile spermatozoa. Risks are minimal, provided the multiple gestation incidence can be reduced to an acceptable level and provided at least one tube is patent. Therefore, in developing countries, reflection on the implementation and use of IUI as a first-line treatment for most cases of non-tubal infertility seems mandatory. The costs are minimal, training is easy, quality control possible and severe complications are almost non-existing. In cases of unexplained infertility or combined male subfertility and ovulatory dysfunction, correction and/or ovarian stimulation with clomiphene citrate (CC) is probably the best strategy from a cost-benefit point of view unless CC-resistancy has been proven in which the use of low-dose gonadotrophins is necessary.