Introduction

The treatment options that face a couple prior to IVF essentially depend upon the cause of their infertility. The surgical techniques to treat mild or moderate endometriosis will not be discussed here neither will we enter the debate of surgery (open or laparoscopic) versus IVF for distal tubal disease. This chapter will discuss the role of controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) in the management of mild male factor subfertility, endometriosis and ovulation induction in anovulatory infertility, and will concentrate on the management of unexplained subfertility.

Male factor subfertility

Severe male factor subfertility is treated by intracytoplasmic sperm injection (ICSI) after excluding carrier status for cystic fibrosis and performing a karyotype. However, the point at which a physician should advise a trial of COH-IUI prior to embarking on the more ‘medicalized’ procedure of IVF-ICSI is controversial. A meta-analysis of couples with male factor infertility suggested that the chance of conception with male factor subfertility is half that of other couples with other causes of subfertility after IUI – odds ratio 0.48 after stepwise logistic regression (Hughes et al., 1997). In contrast a prospective randomized trial concluded that COH-IUI was equally effective in couples with male factor infertility and unexplained infertility (Goverde et al., 2000). It is therefore important to define the degree of male factor subfertility because inevitably the cycle fecundity will vary according to the degree of oligoasthenozoospermia. In the prospective study of Goverde et al. (2000), male factor subfertility was defined in couples where three out of five semen analyses showed a total motile sperm count of less than 20 million progressively moving sperm in the ejaculate.