Intrauterine insemination versus IVF for treatment of Endometriosis

Authored by H. Shapiro, G.L.A. Horbay, D. vanVugt, P. Hahn, R.L. Reid and R.F. Casper. at the Depts. of OB/GYN, University of Toronto, and Queens University, Kingston, Ontario, Canada.

Controversy exists regarding the importance of systemic autoimme phenomena versus local pelvic pathology in the etiology of endometriosis-related infertility.

Empirically, intrauterine insemination of washed sperm (IUI) and in vitro fertilization (IVF) have both been used as therapy for infertility in endometriosis patients. In our centre, both treatments involve controlled ovarian hyperstimulation using similar protocols and the same sperm wash and swim-up procedure. However, IUI involves ovulation fertilization in vivo, while IVF results in fertilization outside the body, with subsequent transfer
of embryos directly into the uterus.

If systemic factors are important in etiology of infertility, we hypothesized the women with endometriosis would have lower pregnancy rates than women without endometriosis in both IUI and IVF. Conversely, if an adverse pelvic environment is the cause of the infertility, women with endometriosis may have the same pregnancy rates as controls in IVF but lower pregnancy rates with IUI.

To test the hypothesis, we compared the pregnancy rate in endometriosis patients to the rate in patients with male factor infertility or anovulation in our IUI program, and to the rate in patients with tubal factor infertility in the IVF program. There were 77 cycle of IUI in patients with endometriosis and 154 control cycles, with 4 (5.2%/cycle) and 28 (18.2%/cycle) pregnancies respectively (X2=6.8, p<0.01). The cumulative pregnancy rate over three cycles was 10% in the endometriosis group and control cycles resulted in embryo transfer. The fertilization rate was identical in each group, and there were 10 (17.8%/ET) and 164 (20%/ET) pregnancies respectively (X2=0.15, not significant).

The similar pregnancy rates in both groups in the IVF program, in contrast to the lower pregnancy rate in endometriosis patients treated by IUI, suggests that possible adverse peritoneal factors in endometriosis may be bypassed byIVF. Our data do not support the concept that any systemic factor is a major cause of the infertility in endometriosis.

Copyright © 1997, Toronto Centre for Advanced Reproductive Technology

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