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Deficiencies in reporting results of lesbians and gays after donor intrauterine insemination and assisted reproductive technology treatments: A review of the first emerging studies

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At a time when increasing numbers of lesbians and gays consider parenthood using reproductive assistance in infertility centers, the present review aims to summarize the results obtained so far by lesbians after intrauterine insemination (IUI) and in-vitro fertilization (IVF) using donor spermatozoa (D-IUI and D-IVF, respectively) and gays entering into gestational-surrogacy programs. Data show that gays display normal semen parameters and lesbians exhibit no specific causes of female infertility except perhaps for polycystic ovary syndrome (PCOS) and some PCOS-related factors. Pair-bonded lesbians entering into D-IUI programs, tend to have higher pregnancy and delivery percentages following spontaneous or induced ovulation than single or pair-bound heterosexual women. The only single study reporting success percentages of lesbians after D-IVF provides, however, puzzling results. In particular, pair-bonded lesbians have lower pregnancy and live-birth percentages than pair-bonded heterosexual women in fresh D-IVF cycles but percentages are similar in frozen/thawed D-IVF cycles. Like in lesbians after D-IUI, surrogate women recruited by pair-bonded gays/single men tend to have higher pregnancy percentages and lower miscarriage percentages than surrogate women recruited by heterosexual couples. Notably, all the reports reviewed in the present study are methodologically flawed because of sampling bias, small sample sizes and inadequate use of statistical methods to control for the effects of influential covariates including age, smoking habits, previous gynecological problems, hormonal stimulation type and protocol, and number of prior treatment types and pregnancies/deliveries. Clinicians, reproductive biologists and editors of fertility/infertility journals should make efforts to prevent these deficiencies in future data reporting.
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R E V I E W Open Access
Deficiencies in reporting results of lesbians and
gays after donor intrauterine insemination and
assisted reproductive technology treatments: a
review of the first emerging studies
Juan J. Tarín
1*
, Miguel A. García-Pérez
2,3
and Antonio Cano
4,5
Abstract
At a time when increasing numbers of lesbians and gays consider parenthood using reproductive assistance in
infertility centers, the present review aims to summarize the results obtained so far by lesbians after intrauterine
insemination (IUI) and in-vitro fertilization (IVF) using donor spermatozoa (D-IUI and D-IVF, respectively) and gays
entering into gestational-surrogacy programs. Data show that gays display normal semen parameters and lesbians
exhibit no specific causes of female infertility except perhaps for polycystic ovary syndrome (PCOS) and some
PCOS-related factors. Pair-bonded lesbians entering into D-IUI programs, tend to have higher pregnancy and
delivery percentages following spontaneous or induced ovulation than single or pair-bound heterosexual women.
The only single study reporting success percentages of lesbians after D-IVF provides, however, puzzling results. In
particular, pair-bonded lesbians have lower pregnancy and live-birth percentages than pair-bonded heterosexual
women in fresh D-IVF cycles but percentages are similar in frozen/thawed D-IVF cycles. Like in lesbians after D-IUI,
surrogate women recruited by pair-bonded gays/single men tend to have higher pregnancy percentages and lower
miscarriage percentages than surrogate women recruited by heterosexual couples. Notably, all the reports reviewed
in the present study are methodologically flawed because of sampling bias, small sample sizes and inadequate use
of statistical methods to control for the effects of influential covariates including age, smoking habits, previous
gynecological problems, hormonal stimulation type and protocol, and number of prior treatment types and
pregnancies/deliveries. Clinicians, reproductive biologists and editors of fertility/infertility journals should make
efforts to prevent these deficiencies in future data reporting.
Keywords: Cause of infertility, Donor intrauterine insemination, In-vitro fertilization, Oocyte-donation cycles, Semen
parameters, Sexual orientation, Gestational surrogacy
Background
It has been reported that gays and lesbians reproduce
significantly less than heterosexual subjects. For instance
in one U.S. random-sample survey performed in 1994,
only 27 % of men who identified as homosexual said
they were fathers, compared with 60 % of other men.
Differences between groups were smaller in women but
the percentage was also lower in lesbians (67 % versus
72 % in other women) (for review, see [1]). Iemmola and
Camperio-Ciani [2] found in an Italian survey that non-
heterosexual men (bisexuals were also included in this
group) had significantly fewer children than heterosex-
ual men (an average of 0.12 versus 0.58 children/man).
Dissimilarities were even larger in a British study [3]
with an average of 0.002 children/man in exclusive
white homosexuals versus 0.36 children/man in white
heterosexuals.
Despite differences in number of children fathered,
there are no reasons to think that the potential for
reproduction of homosexuals is decreased when com-
pared with heterosexuals. Firstly, sexual preference is gov-
erned by the brain independently of plasma concentrations
* Correspondence: tarinjj@uv.es
1
Department of Functional Biology and Physical Anthropology, Faculty of
Biological Sciences, University of Valencia, Burjassot, Valencia 46100, Spain
Full list of author information is available at the end of the article
© 2015 Tarín et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Tarín et al. Reproductive Biology and Endocrinology (2015) 13:52
DOI 10.1186/s12958-015-0053-9
of sex hormones as shown in the mouse model [4]. Like-
wise, plasmatic/salivary levels of sex hormones are not as-
sociated with sexual orientation in human beings (see
later). Secondly, there are more obvious reasons than de-
creased potential for reproduction to explain discrepancies
in number of children fathered between homosexuals and
heterosexuals. For instance, homosexuals do not engage in
sexual activities with individuals of the opposite sex as fre-
quently as heterosexuals.
Thanks to the social changes taking place in Western
society with respect to gay rights increasing numbers of
lesbians and gays seek reproductive assistance to achieve
parenthood in infertility centers. Consequently, a num-
ber of studies reporting success percentages of lesbians after
intrauterine insemination (IUI) and in-vitro fertilization
(IVF) using donor spermatozoa (D-IUI and D-IVF, respect-
ively) and gays entering into gestational-surrogacy pro-
grams are starting to emerge.
A priori, success percentages of lesbians and gays
should be similar or even higher than those exhibited by
heterosexuals attending infertility clinics. Actually, al-
though some studies suggest that some lesbians have
higher testosterone levels than heterosexual women, es-
pecially those that adopt a masculine role in their couple
relationship [5, 6], most studies find no significant differ-
ences between homosexual and heterosexual subjects in
adult plasmatic/salivary levels of sex hormones and go-
nadotropins, and secretion pattern of gonadotropins
([710] for reviews see [1113]). In addition, pair-
bonded lesbians usually enter into D-IUI and/or D-IVF
programs to fulfill their wishes to get pregnant and have
their own offspring, not because they are infertile. In
contrast, most women from heterosexual couples attend
reproductive health clinics to undergo D-IUI and/or D-
IVF because their partner is an infertile man, human im-
mune virus (HIV)-positive, or carries another sexually
transmitted disease or a genetic disease. Of note, women
with an infertile partner may be as well subfertile, espe-
cially when their partner suffers from oligozoospermia
[14]. Moreover, lesbians may have a higher incidence of
polycystic ovary syndrome (PCOS) and some PCOS-
related factors including polycystic ovaries (see later),
circumstances that may increase further the success per-
centages after D-IUI and/or D-IVF. Indeed, women with
PCOS going through IUI [1517] and women with poly-
cystic ovaries undergoing IVF and/or intracytoplasmic
sperm injection (ICSI) treatment [1820] exhibit in-
creased pregnancy and live-birth/delivery percentages.
Likewise pair-bonded gays usually enter into gesta-
tional surrogacy programs to fulfill their desire to raise
children, create families and pass on their genes to off-
spring (for references, see [21]), not because they are in-
fertile. In contrast, pair-bonded heterosexual men use
these programs because their partner (a) has previously
experienced repeated implantation failure, unexplained
or failed treatment for recurrent pregnancy loss, or poor
obstetrical history; (b) has no uterus (congenital or post-
hysterectomy) or a severe Müllerian anomaly; (c) suffers
from a medical condition where pregnancy could pose a
significant health risk; or (d) takes medications that are
or could potentially be teratogenic [22]. Note that some
of these conditions in particular, recurrent pregnancy
loss [2325] and repeated implantation failure (for re-
view, see [26]) not only may be associated with female
factors but also with male factors.
At a time when increasing numbers of lesbians and
gays consider parenthood using reproductive assistance
in infertility centers [22] the present review aims to
summarize the results obtained so far by lesbians after
D-IUI and D-IVF and gays entering into gestational-
surrogacy programs. This information may be helpful
not only to future intended homosexual parents seeking
reproductive assistance in infertility centers but also to
clinicians and reproductive biologists assisting this col-
lective. We are aware that human sexual behavior is
highly complex and variable and sexuality is much
more complex and individual than a simpler bipolar
(heterosexual versus homosexual) classification [27].
However, for the sake of simplicity and pragmatism, we
use the traditional bipolar classification.
Methods
A literature review based on publications up to February
2015 identified by PubMed database searches using the
following key words: lesbians, gays, homosexuals, hetero-
sexuals, sexual orientation, fertility, infertility, gestational
surrogacy, reproductive fitness, intrauterine insemination,
in vitro fertilization, testosterone, estradiol, steroids, hor-
mone profiles, gonadotropins, oligozoospermia, terato-
zoospermia, asthenozoospermia, normozoospermia. In
addition, a hand search was done to explore the references
cited in the primary articles. This literature search evi-
denced 4 and 2 articles reporting success percentages of
lesbians and gays, respectively, after D-IUI and assisted re-
productive technology treatments (see Tables 1 and 2). All
these articles were analyzed without applying inclusion or
exclusion criteria.
For the sake of uniformity, data from 2 × 2 and 3 × 2
contingency tables were re-analyzed using Pearson's
chi-square test. Fishers exact test was applied in the
analysis of 2 × 2 contingency tables if the expected
values in any of the cells were less than 5. Data re-
analysis was performed using the IBM SPSS Statistics,
Version 22 (© Copyright IBM corporation et al. 1989,
2013). P values from tests comparing continuous vari-
ables were kept in their original form. Significance was
defined as P 0.05.
Tarín et al. Reproductive Biology and Endocrinology (2015) 13:52 Page 2 of 7
Causes of infertility in lesbians
Despite a higher prevalence of Chlamydia infection [28,
29], the incidence of tubal-factor infertility in lesbians is
similar to that found in heterosexual women [2931].
However, two articles [10, 31] have reported that, com-
pared with heterosexual women, lesbians may exhibit
higher prevalence of PCOS and some PCOS-related fac-
tors including polycystic ovaries, hirsutism, obesity, and
Table 1 Success percentages of lesbians after D-IUI,fresh D-IVF and frozen/thawed D-IVF
Treatment Outcome Ovarian
stimulation
Lesbians Pair-bonded
lesbians
Pair-bonded
heterosexual
women
Single women Single
heterosexual
women
Pvalue Reference
D-IUI Pregnancy per cycle None 22.2 (10/45)
a
8.8 (19/217) 0.016
b
Ferrara
et al. [30]
hMG 20.8 (5/24) 10.4 (14/134) 0.172
b
Ferrara
et al. [30]
CC 7.2 (5/69) 5.4 (10/185) 0.560
b
Ferrara
et al. [30]
None, CC
or hMG
13.5
(26/192)
9.6 (83/864) 0.105
c
Ferrara
et al. [38]
None, CC, FSH
or CC+ FSH
20.5 (90/438) 14.8 (44/298) 0.046
c
Nordqvist
et al. [29]
Ongoing pregnancy
per woman after a
mean number of
3 cycles
None, CC or
gonadotropins
60 %
(72/120)
d
55 %
(72/131)
d
0.203
c
De Sutter
et al. [33]
Pregnancy per
woman after a mean
number of 3 cycles
e
None, CC, FSH
or CC+ FSH
61.6 (90/146) 44.0 (44/100) 0.006
c
Nordqvist
et al. [29]
Live-birth per cycle None, CC, FSH
or CC+ FSH
16.0 (70/438) 12.8 (38/298) 0.224
c
Nordqvist
et al. [29]
Live-birth per woman
after a mean number
of 3 cycles
e
None, CC, FSH
or CC+ FSH
48.0 (70/146) 38.0 (38/100) 0.123
c
Nordqvist
et al. [29]
Fresh
D-IVF
Pregnancy per cycle Not specified 34.6 (44/127) 45.2 (57/126) 0.085
c
Nordqvist
et al. [29]
Pregnancy per
woman after a mean
number of 1.5
cycles
f
Not specified 47.8 (44/92) 68.7 (57/83) 0.005
c
Nordqvist
et al. [29]
Live-birth per cycle Not specified 27.6 (35/127) 33.3 (42/126) 0.318
c
Nordqvist
et al. [29]
Live-birth per woman
after a mean number
of 1.5 cycles
f
Not specified 38.0 (35/92) 50.6 (42/83) 0.095
c
Nordqvist
et al. [29]
Frozen/
thawed
D-IVF
Pregnancy per cycle Not specified 31.6 (31/98) 31.7 (33/104) 0.988
c
Nordqvist
et al. [29]
Pregnancy per
woman after a mean
number of 2 cycles
g
Not specified 63.3 (31/49) 64.7 (33/51) 0.881
c
Nordqvist
et al. [29]
Live-birth per cycle Not specified 24.5 (24/98) 23.1 (24/104) 0.814
c
Nordqvist
et al. [29]
Live-birth per woman
after a mean number
of 2 cycles
g
Not specified 49.0 (24/49) 47.1 (24/51) 0.848
c
Nordqvist
et al. [29]
a
Counts used to calculate percentages are shown in parentheses
b
2 × 2 contingency Fishers exact test
c
2 × 2 conting ency Pearsons chi-square test
d
Data were represented in a graphical format. Thus, we do not know the exact number of women with an ongoing pregnancy
e
3.00 (438/146) and 2.98 (298/100) D-IUI cycles per woman in the lesbian and heterosexual group, respectively
f
1.38 (127/92) and 1.52 (126/83) D-IVF cycles per woman in the lesbian and heterosexual group, respectively
g
2.00 (98/49) and 2.04 (104/51) D-IVF cycles per woman in the lesbian and heterosexual group, respectively
Tarín et al. Reproductive Biology and Endocrinology (2015) 13:52 Page 3 of 7
higher testosterone and androstenedione levels. A third
study [32] has shown that although lesbians with PCOS
display higher body mass index than heterosexual women
with PCOS, they have similar hyperandrogenism-related
clinical or biochemical characteristics. Likewise, other
studies [29, 33] have found no significant differences in in-
cidence of PCOS and polycystic ovaries between lesbians
and heterosexual women.
Seminal parameters in gays
There is a total absence of current studies reporting
seminal parameters in gays. Just a limited number of ar-
ticles published in the 60sand70s decades dealt with
this topic. Most of them evidenced no significant differ-
ences in semen parameters between homosexual and
heterosexual men [3436]. Only one article by Kolodny
et al. [37] reported the presence of significant differ-
ences in sperm counts among groups of homosexuals
established according to the Kinseys heterosexual-
homosexual rating scale. In particular, azoospermia and
oligozoospermia were concentrated in men with ratings
5 or 6 on the Kinseys scale, i.e., men almost exclusively
or exclusively homosexuals, respectively. These data,
however, should be taken with caution because Kolodny
et al. [37] did not control for several covariates that
may influence seminal parameters such as health status,
use of psychotropic drugs, and degree of physical exer-
cise and sexual activity. In addition, the Kinseysrating
procedure did not discriminate between overt behavior
only or the subjectsgeneral sexual responsiveness in-
cluding attraction and fantasies.
Success percentages of lesbians after D-IUI and D-IVF
D-IUI
Table 1 shows that lesbians tend to have higher success
percentages than heterosexual women after D-IUI. Fer-
rara et al. [30] reported a significantly higher pregnancy
percentage per D-IUI cycle in pair-bonded lesbians fol-
lowing spontaneous ovulation than in single women
(22.2 %, versus 8.8 %). After ovarian stimulation with go-
nadotropins (20.8 % versus 10.4 %) or clomiphene citrate
(7.2 % versus 5.4 %), pair-bonded lesbians still showed
higher pregnancy percentage per cycle although differ-
ences were not significant. Differences between groups
may be explained by the younger age of pair-bonded les-
bians (mean age: 34.5 years; range: 2644 years) com-
pared with single women (mean age: 38.5; range: 2947
years; P 0.005). Furthermore, some single women may
have had a previous infertile relationship with a hetero-
sexual partner and, therefore, at least some of them may
have been subfertile. We should note, however, that
pair-bonded lesbians under 35 years of age exhibited
higher, although not statistically significant, pregnancy
percentage per D-IUI cycle than single women from the
same age group (23.9 %, 16/67 versus 11.5 %, 7/61; Pear-
sons chi-square test: P 0.068). Likewise, in women 30
35 years old, miscarriage percentage per pregnant
woman was significantly lower in pair-bonded lesbians
(10.0 %, 1/10 versus 66.7 %, 4/6 in single women; Fish-
ers exact test: P 0.036). Noteworthy, differences be-
tween groups may have been even higher if we take into
account that some lesbians may have been included in-
correctly in the group of single women. A later study
from the same group [38] reported also a higher, al-
though not significant, pregnancy percentage per D-IUI
cycle in lesbians compared with single heterosexual
women (13.5 % versus 9.6 %). Of note, Ferrara et al. [38]
on this occasion did not specify whether or not lesbians
were pair-bonded and did not compare the effect of
ovarian stimulation on pregnancy percentage between
lesbians and heterosexual women.
Another study by De Sutter et al. [33] evidenced a
non-significant higher ongoing pregnancy percentage
per woman in pair-bonded lesbians than in pair-bonded
Table 2 Success percentages of gays entering into gestational-surrogacy programs
Treatment Outcome Pair-bonded
gays/single men
Heterosexual
couples
Failed to
carry
heterosexual
couples
a
Cannot carry
pregnancy
hererosexual
couples
b
P
value
Reference
Gestational-
surrogacy
program
Delivery per surrogate woman after a
maximum of either two fresh cycles or
one fresh and one frozen transfer
cycle
55.6 (25/45)
c
48.9 (23/47) 0.525
d
Grover et al. [21]
Pregnancy per cycle
f
59.7 (37/62) 50.0 (66/132) 54.0 (75/139) 0.447
e
Dar et al. [22]
Miscarriage per pregnant surrogate
woman
10.8 (4/37) 25.8 (17/66) 20.0 % (15/75) 0.193
e
Dar et al. [22]
a
96 pati ents suffering from recurrent implantation failure (n = 57), recurrent pregnancy loss (n = 30) and previous poor pregnancy outcome (n = 9)
b
108 patients suffering from uterine malformations/Ashermans syndrome (n = 34), Müllerian agenesis (MayerRokitanskyKusterHauser syndrome; n = 33) and
maternal medical conditions precluding pregnancy (n = 41)
c
Counts used to calculate percentages are shown in parentheses
d
2 × 2 contingency Pearsons chi-square test
e
3 × 2 contingency Pearsons chi-square test
f
A cycle was defined as one stimulation cycle with fresh transfer and any subsequent frozen embryo transfer from the same cycle
Tarín et al. Reproductive Biology and Endocrinology (2015) 13:52 Page 4 of 7
heterosexual women (60 % versus 55 %) after a mean
number of 3 D-IUI cycles. Notwithstanding, this study
did not either control for womens age (mean age:
30.6 years in lesbians versus 31.9 years in heterosexuals)
and hormonal stimulation [none, clomiphene citrate
(CC) or gonadotropins]. We should bear in mind that,
in contrast to Pearsons chi-square test, binary logistic
regression models allow you to control for categorical,
interval or continuous covariates.
More recently, Nordqvist et al. [29] have reported a
significantly higher pregnancy percentage per D-IUI
cycle (20.5 % versus 14.8 %) and per woman after a
mean number of 3 D-IUI cycles (61.6 % versus 44.0 %)
in pair-bonded lesbians compared with pair-bonded het-
erosexual women. Live-birth percentage per D-IUI cycle
(16.0 % versus 12.8 %) and per woman after a mean
number of 3 D-IUI cycles (48.0 % versus 38.0 %) were
also higher in the homosexual group, although differ-
ences were not significant. Like in the other previous
studies, Nordqvist et al. [29] did not control for influ-
ential covariates including: (1) hormonal stimulation
[none, CC, follicle stimulating hormone (FSH) or CC+
FSH]; (2) smoking habits (2.8 % of lesbians and 9.2 % of
heterosexuals were smokers); (3) previous gynecological
problems (the incidence of several previous gynecological
problems in lesbians was at least twice as high as in het-
erosexuals); (4) number of prior treatments (lesbians had
previously undergone D-IUI and D-IVF more often than
heterosexuals, whereas heterosexuals had previously
undergone ICSI with partner sperm more often than les-
bians); and (5) previous pregnancies/deliveries (heterosex-
uals exhibited higher incidence of previous deliveries than
lesbians). Womens age was, however, homogenous in
both groups (mean ± standard deviation: 32.4 ± 4 years).
D-IVF
Nordqvist et al. [29] compared success percentages be-
tween pair-bonded lesbians and pair-bonded heterosex-
ual women after fresh and frozen/thawed D-IVF
(Table 1). On this occasion, pregnancy percentage per
fresh D-IVF cycle (34.6 % versus 45.2 %) and per woman
after a mean number of 1.5 fresh D-IVF cycles (47.8 %
versus 68.7 %) were lower in the lesbian group. Live-
birth percentage per fresh D-IVF cycle (27.6 %, versus
33.3 %) and per woman after a mean number of 1.5
fresh D-IVF cycles (38.0 % versus 50.6 %) were also
lower in the lesbian group although differences were not
significant. These results contrast with the similar suc-
cess percentages obtained in frozen/thawed D-IVF cy-
cles. In particular, the pregnancy percentage per cycle
was 31.6 % versus 31.7 % and the pregnancy percentage
per woman after a mean number of 2 cycles was
63.3 % versus 64.7 % in the lesbian and heterosexual
group, respectively. Likewise, live-birth percentage per
frozen/thawed D-IVF cycle (24.5 % versus 23.1 %) and
per woman after a mean number of 2 frozen/thawed
D-IVF cycles (49.0 % versus 47.1 %) were also similar in
pair-bonded lesbians and pair-bonded heterosexuals.
Sampling bias, small sample sizes and inadequate use
of statistical methods to control for the effects of influ-
ential covariates may explain discrepancies in success
percentages of pair-bonded lesbians and pair-bonded
heterosexual women reported by Nordqvist et al. [29]
after D-IUI, fresh D-IVF and frozen/thawed D-IVF.
Success percentages of gays in gestational-surrogacy
programs
Like in lesbians after D-IUI, gays entering into gestational-
surrogacy programs tend to have higher success percent-
ages than heterosexual men (Table 2). Grover et al. [21]
reported that 56.8 % (21/37) of surrogate women recruited
by pair-bonded gays and 50.0 % (4/8) of surrogate women
recruited by single men (7 homosexuals and one hetero-
sexual) succeeded in achieving a pregnancy after a max-
imum of either two fresh cycles or one fresh and one
frozen transfer cycle. No significant differences in delivery
percentages per surrogate woman between the group of
pair-bonded gays/single men and a control group of het-
erosexual couples were evidenced (55.6 % versus 48.9 %).
Of note, this study did not control for the potential nega-
tive effects of male reproductive aging on semen parame-
ters and embryo/fetal development (for review, see [39]).
Furthermore, the study did not provide any information
about epidemiological data of heterosexual couples, oo-
cyte donors and gestational carriers including ovarian
stimulation protocol and medical indications for using
gestational surrogacy.
These deficiencies were partially amended in a recent
study by the same group [22]. This study reported the
largest gestational surrogacy series published so far (333
consecutive gestational surrogacy cycles including cycles
from most of the pair-bonded gays and single men pre-
viously reported by Grover et al. [21]). On this occasion,
the medical indications of heterosexual couples for using
gestational surrogacy were specified. Notwithstanding,
data analysis were either not controlled for ovarian
stimulation protocol and age of intended parents, oocyte
donors and gestational carriers. In addition, the group of
heterosexual couples was not homogeneous. In fact,
intended heterosexual parents used donor oocytes in
39.5 % (107/271) of cycles (mean age of oocyte donors:
26.2 years) whereas in the remaining 60.5 % (164/271) of
cycles (mean womens age: 36.1 years) they used their
own (autologous) oocytes. Furthermore, the group of
heterosexual couples included a total of 17 cycles in
which embryos were concurrently transferred to both
the intended-parent woman and the gestational carrier.
In contrast, all the 52 pair-bonded gays/single men
Tarín et al. Reproductive Biology and Endocrinology (2015) 13:52 Page 5 of 7
entered into the study used exclusively donor oocytes
and gestational carriers.
The sampling asymmetries/biases between groups may
explain, at least in part, the higher, although not statisti-
cally significant, pregnancy percentage per cycle evi-
denced in the pair-bonded gays/single mengroup
(59.7 %) compared with a failed to carry(50.0 %) and a
cannot carry pregnancy(54.0 %) group. Likewise, the
pair-bonded gays/single mengroup displayed lower
miscarriage percentages per pregnant surrogate woman
(10.8 %) than the failed to carry(25.8 %) and the can-
not carry pregnancy(20.0 %) group, although differ-
ences among groups were not statistically significant.
Concluding remarks
The present review shows that lesbians after D-IUI and
gays entering into gestational-surrogacy programs tend
to have higher success percentages than heterosexuals.
This trend is not surprising if we take into account that
lesbians usually enter into D-IUI programs and gays into
gestational-surrogacy programs to fulfill their wishes to
have and raise their own offspring and create families,
not because they are infertile. However, the only single
study published so far on success percentages of lesbians
after D-IVF [29] provides puzzling results. In particular,
data show that pair-bonded lesbians have lower preg-
nancy and live-birth percentages than pair-bonded het-
erosexual women in fresh D-IVF cycles. In contrast,
pregnancy and live-birth percentages are similar in fro-
zen/thawed D-IVF cycles. Of note, all the reports
reviewed in the present study are methodologically
flawed because of sampling bias, small sample sizes and
inadequate use of statistical methods to control for the
effects of influential covariates including age, smoking
habits, previous gynecological problems, hormonal
stimulation type and protocol, and number of prior
treatment types and pregnancies/deliveries. Clinicians,
reproductive biologists and editors of fertility/infertility
journals should make efforts to prevent these deficien-
cies in future data reporting.
Abbreviations
CC: Clomiphene citrate; D-IUI: Intrauterine insemination with donor
spermatozoa; D-IVF: In-vitro fertilization with donor spermatozoa; FSH: Follicle
stimulating hormone; HIV: Human immune virus; hMG: Human menopausal
gonadotropins; ICSI: Intracytoplasmic sperm injection; IUI: Intrauterine
insemination; IVF: In-vitro fertilization; PCOS: Polycystic ovary syndrome.
Competing interests
The authors declare that they have no competing interests.
Authorscontributions
JJT has been involved in conception and design, acquisition, analysis and
interpretation of data, drafting the article and final approval of the version to
be published. MAGP and AC have been involved in analysis and
interpretation of data, revising the article critically for important intellectual
content and final approval of the version to be published.
Author details
1
Department of Functional Biology and Physical Anthropology, Faculty of
Biological Sciences, University of Valencia, Burjassot, Valencia 46100, Spain.
2
Department of Genetics, Faculty of Biological Sciences, University of
Valencia, Burjassot, Valencia 46100, Spain.
3
Research Unit-INCLIVA, Hospital
Clínico de Valencia, Valencia 46010, Spain.
4
Department of Pediatrics,
Obstetrics and Gynecology, Faculty of Medicine, University of Valencia,
Valencia 46010, Spain.
5
Service of Obstetrics and Gynecology, University
Clinic Hospital, Valencia 46010, Spain.
Received: 2 March 2015 Accepted: 27 May 2015
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Tarín et al. Reproductive Biology and Endocrinology (2015) 13:52 Page 7 of 7
... Lesbian and single women presenting to fertility clinics to access assisted reproductive technologies (ART) may not meet standard criteria for infertility diagnoses. In fact, one could hypothesize that this population would have similar if not higher rates of reproductive success when compared with heterosexual couples seeing reproductive endocrinologists [5]. A prior study that controlled for age and hormonal stimulation showed that lesbian couples have higher pregnancy rates than single women [6]. ...
... only showed a significantly higher pregnancy rate in lesbian couples but not an increase in live birth rate [23]. Methodologic flaws have been highlighted including a small sample size and poorly controlling for confounders [5]. In the present study, we used a larger sample size and controlled for important confounders finding that an added benefit for second insemination was not seen in lesbian and single women. ...
... To the authors' knowledge, this is the largest study of IUI outcomes according to sexual orientation and partner status. Other strengths of the study include an improvement upon prior studies investigating single women and lesbian patients by using a large sample size and by using multivariable analysis controlled for multiple cycles contributed by the same woman, along with addressing important confounders such as age, D3 FSH, BMI, peak E2, and post-wash total motile counts [5]. Given that a majority (58%) of pregnancy losses after ART occur before 6 weeks' gestation, we used OPR, defined as fetal cardiac activity > 7 weeks, as a surrogate marker in this study [24]. ...
Article
Full-text available
Purpose To explore clinical benefit of performing two intrauterine inseminations (IUI) 24 h apart—a double IUI vs. a single IUI among lesbian and single women. Methods Retrospective cohort study using electronic medical record review during a 17-year period (11/1999–3/2017). A total of 11,396 patients at a single academic-affiliated private practice were included in this study. All cycles with a single or double IUI were included. A sub-analysis of first cycles only (n = 10,413) was also performed. Canceled IVF cycles converted to IUI were excluded. T tests and Wilcoxon rank-sum tests were used for continuous data, and chi-square for categorical data. Multivariable logistic regression controlled for patient age, day 3 follicle-stimulating hormone (D3 FSH), body mass index (BMI), peak estradiol (E2), and post-wash total motile sperm counts to model the association between IUI number and ongoing pregnancy rate (OPR) according to sperm source (autologous vs. donor). Generalized estimating equations and mixed effect models accounted for multiple cycles from the same woman. Adjusted odds ratio (AOR) with 95% CI was determined. Sub-analyses of sexual orientation and partner status were performed to compare heterosexual couples with proven infertility to women with lesbian and single women. Results During the study period, 22,452 cycles met inclusion criteria (single IUI 1283 vs. double IUI 21,169). Mean patient age and BMI were similar between groups. For couples using autologous sperm, OPR was significantly higher with double IUI (12.0% vs. 14.1%; p = 0.0380). A similar increase was observed for donor sperm OPR among heterosexual couples (14.4% vs. 16.2%), though this did not reach statistical significance (p = 0.395). A sub-analysis restricted to donor sperm demonstrates a clinical benefit of second IUI in heterosexual couples, 8.5% vs. 17.6% OPR (AOR 2.94; CI 1.00–10.99; p = 0.0496). When lesbian and single patients were evaluated, there was no difference (17.2% vs. 15.2%; AOR 0.99; CI 0.59–1.70; p = 0.0958). Conclusions Double IUI is associated with a significantly higher OPR for heterosexual couples using an autologous or donor sperm source. The benefit of a second IUI is less clear in patients with undocumented fertility status using donor sperm, such as single and lesbian women.
... Regarding the LGBT patient population specifically, current research on the use of donor sperm IUI and IVF is still limited and with conflicting results [3,[15][16][17][18]. While some of the literature shows higher pregnancy and live birth rates in lesbian women undergoing IUI and fresh IVF cycles compared to heterosexual couples, other existing studies demonstrate no difference. ...
Article
Full-text available
PurposeTo report fertility treatment use and outcomes among patients who use donor sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), and reciprocal IVF (co-IVF).Methods This is a retrospective review of patients who used donor sperm at an urban, southeastern academic reproductive center between 2014 and 2020.ResultsAmong the 374 patients presenting for care, 88 (23.5%) were single, 188 (50.3%) were in a same-sex female partnership, and 98 (26.2%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). A total of 1106 cycles were completed, of which there were 931 IUI cycles, 146 traditional IVF cycles, and 31 co-IVF cycles. Live birth rates per cycle were 11% in IUI, 42% in IVF, and 61% in co-IVF. Of all resulting pregnancies, hypertensive disorders were most commonly experienced (18.0%), followed by preterm delivery (15.3%), neonatal complications (9.5%), gestational diabetes (4.8%), and fetal growth restriction (4.8%). Of the 198 infants born, fifteen (8.3%) required admission to the neonatal intensive care unit and three (1.7%) demised. Pregnancy and neonatal complications were more likely to occur in older patients and patients with elevated body mass index.Conclusion The use of donor sperm for fertility treatment is increasing. These data show reassuring live birth rates; however, they also highlight the risks of subsequent pregnancy complications. With the expansion of fertility treatment options for patients, these data assist provider counseling of patients regarding anticipated cycle success rates and possible pregnancy complications.
... We acknowledge several limitations to our study, including only being descriptive. Until sexual orientation and gender identity data are routinely collected in the clinical setting, studies will continue to suffer from methodological flaws and be limited to smaller sample sizes resulting in the aggregation of distinct sexual and gender minority subgroups together (54). Furthermore, several of the studies cited in this discussion section remain unpublished, probably due, in part, to the aforementioned limitations. ...
Article
Full-text available
Objective To explore cycle characteristics and outcomes of single and coupled intended fathers using assisted reproductive technology. Design Cross-sectional study. Setting Multi-center, fertility practices in the U.S. from 2016-2021. Patient(s) In this study, cycles among single and coupled intended fathers with access to fertility coverage from 2016-2021 were included. Intervention(s) None Main Outcome Measure(s) Our primary outcome was live birth rate. Secondary outcomes included the number of embryos transferred, miscarriage rate, and incidence of multifetal birth. Results Five single and 39 coupled intended fathers completed an IVF cycle with a majority using egg donation and an agency-based gestational surrogate (69.7%; 83/119). In the majority of couples, both partners wanted to serve as the sperm source (64.4%, 29/45). The vast majority (97.7%;43/44) also utilized PGT-A. Among the embryo transfer (ET) cycles (n=27), most consisted of a single euploid ET (74.07%; 20/27); while the remaining consisted of a double euploid ET (25.92%; 7/27). The single and coupled intended fathers had high rates of success, with a live birth rate of 85.19% (23/27). An average of 1.26 ± 0.44 embryos were transferred, with a majority resulting in singleton birth (70.37%; 19/27). Conclusion Our study of single and coupled intended fathers using ART in the U.S. demonstrates that this population share similar preferences for sperm source and use of preimplantation genetic testing. Clinical outcomes suggest this population is successful at achieving a live birth when using egg donation and a gestational carrier.
... A more recent study that compared SW, lesbian and heterosexual couples found no difference in pregnancy rates after D-IUI treatments [17]. In studies showing higher pregnancy rates in lesbian couples compared to heterosexual couples, it is sometimes difficult to see if confounders for infertility in heterosexual couples undergoing ART compared to lesbian couples with social infertility are considered which make it difficult to interpret study results [18]. her medical and psychosocial evaluation in November 2017, and the first ART treatment with donated sperm was performed in January 2018. ...
Article
Full-text available
Purpose Assisted reproductive technology (ART) treatments with donor sperm have been allowed for women in lesbian relationships (WLR) since 2005 in Sweden, but for single women (SW), these became approved only recently in 2016. This study was conducted to compare the outcomes of ART treatments in SW vs. WLR. Methods This is a prospective controlled cohort study of 251 women undergoing intrauterine insemination (D-IUI) or in vitro fertilization (D-IVF) using donor sperm between 2017 and 2019 at the department of Reproductive Medicine, Karolinska University Hospital. The cohort comprised 139 SW and 112 WLR. The main outcomes included differences in live birth rate (LBR) and cumulative live birth rate (cLBR) between the groups. The SW underwent 66 D-IUI and 193 D-IVF treatments and WLR underwent 255 D-IUI and 69 D-IVF treatments. Data on clinical characteristics, treatment protocols and clinical outcomes were extracted from the clinic’s electronic database. The outcomes of D-IUI and D-IVF were separately assessed. Results The cohort of SW was significantly older than WLR (37.6 vs. 32.4 years, P < 0.001), and more commonly underwent IVF at first treatment (83% vs. 29%, P < 0.000). Conversely, WLR underwent more frequently D-IUI as a first treatment (71% vs. 17% of SW, P < 0.001) and more often in the natural cycle (89.9% vs. 70.8%, P = 0.019), respectively. There was no statistically significant difference in the main outcome LBR between the two groups, or between the two different types of treatment, when adjusted for age. Perinatal outcomes and cLBR were also similar among the groups. Conclusions SW were, on average, older than WLR undergoing treatment with donor sperm. No significant differences were seen in the LBR and cLBR when adjusted for age between the two groups and between the two types of treatment (D-IVF vs. D-IUI). Trial registration ClinicalTrials.gov NTC04602962.
... AID is performed to assist couples in which the male partner has severe oligozoospermia or azoospermia and single or lesbian women who would like to have children (Pfeifer et al. 2013;Nordqvist et al. 2014;Tarín et al. 2015). IUI with fresh donor sperm has been abandoned due to the risk of transmission of infectious disease, such as human immunodeficiency virus and hepatitis B and C (Pfeifer et al. 2013). ...
Article
This retrospective study evaluated the association between frozen donor sperm used for intrauterine insemination and clinical and neonatal outcomes, including 304 singleton pregnancies resulting from artificial insemination by the husband (AIH) and 173 singleton pregnancies resulting from artificial insemination by a donor (AID). The clinical outcomes for AID showed no increased risk of abortion, ectopic pregnancy or pregnancy complications compared to those for AIH. There were no differences in gender, gestational age or prematurity of live births between the two groups. However, the birthweight of live births from AID was significantly higher than that from AIH. Moreover, the AID group exhibited no increased risk of stillbirths or fetal defects compared to the AIH group. These results indicate that frozen donor sperm did not increase the occurrence of adverse clinical and neonatal outcomes when compared to sperm from the husband. Abbreviations: AID: artificial insemination by a donor; AIH: artificial insemination by the husband; ART: assisted reproduction technology; FET: frozen embryo transfer; IVF: in vitro fertilization; ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; LBW: low birth weight
... Threat to identity resulting from cancer related infertility has been reported to be more common in individuals who identity as heterosexual [75], who formed the majority of participants in our study, as masculinity and femininity are performed through engagement in heteronormative gendered practice [76]. However, lesbian, gay and bisexual identified participants also reported fertility concerns, and infertility is an issue for many lesbian, gay, bisexual, transgender and intersex (LGBTI) individuals [77]. There is currently an absence of research on LGBTI fertility concerns in the context of cancer, as well as an absence of targeted information and support. ...
Article
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Background: Infertility is a major concern for people with cancer and their partners. There have been calls for further research on the gendered nature of psychosocial, emotional and identity concomitants of fertility post-cancer across women and men. Method: The gendered construction and experience of infertility following cancer was examined through a survey of 693 women and 185 men, and in-depth one-to-one interviews with a subsample of survey respondents, 61 women and 17 men, purposively selected across cancer types and age groups. Thematic decomposition was used to examine the open ended survey responses and interviews. The chi square test for independence was used to test for group differences between women and men on closed survey items. Results: In the thematic decomposition, infertility was identified as providing a 'Threat of Biographical Disruption' which impacted on life course and identity, for both women and men. Subthemes identified were: 'Parenthood as central to adulthood'; 'Infertility as a threat to gender identity'; ' Unknown fertility status and delayed parenthood'; 'Feelings of loss and grief'; 'Absence of understanding and support'; 'Benefit finding and renegotiation of identity'. In the closed survey items, the majority of women and men agreed that they had always 'wanted to be a parent' and that 'parenthood was a more important life goal than a satisfying career'. 'It is hard to feel like a true adult until you have a child' and impact upon 'my feelings about myself as a man or a woman' was reported by both women and men, with significantly more women reporting 'I feel empty because of fertility issues'. Many participants agreed they 'could visualise a happy life without a child' and there is 'freedom without children'. Significantly more men than women reported that they had not discussed fertility with a health care professional. Conclusion: The fear of infertility following cancer, or knowledge of compromised fertility, can have negative effects on identity and psychological wellbeing for both women and men, serving to create biographical disruption. Support from family, partners and health care professionals can facilitate renegotiation of identity and coping.
Article
Purpose To evaluate the size and characteristics of the demand for a newly established, publicly sponsored, program of assisted reproduction for single women (SW) and women with a female partner (FP) in a European country. Materials and methods We analysed the application forms received during the first two years and structured interviews with 300 successive non selected applicants Results The mean sustained size of the demand was of 52.6 applications per month (sd 14) and corresponded to 0.06 % of the target population. Data from 237 applicants was evaluable. 119 (50.2 %) were SW and 118 (49.8 %) were FP. The median age was 36 years, 36.5 years for SW and 34 years for FP (p < 0.001, Mann-Whitney). Clinically 18.6 % of women presented irregular cycles, and 17.8 % of women had undergone hysterosalpingography (HSG), with a 14.3% prevalence of tubal dysfunction. Conclusions A publicly sponsored program for Assisted Reproduction for SWFP should establish clear inclusion criteria, especially as regards to age, ovarian reserve, techniques offered, and the number of cycles to obtain the maximal efficiency. Further research specific for this group is required to ensure that they receive adequate care and ultimately to fulfil their reproductive rights.
Article
The use of assisted reproduction among women in relationships with other women has increased in the United States over the past decade as a result of increased legal access and social acceptance. Despite this shift, limited studies currently exist to guide optimal fertility care for this growing patient population of women seeking assisted reproduction. In this Commentary, assisted reproduction will be meant to include ovulation induction, intrauterine insemination (IUI), and in vitro fertilization (IVF). Conflicting studies suggest that self-identified lesbian women may demonstrate an increased prevalence of polycystic ovarian syndrome. Most available studies find that a woman's sexual orientation does not affect the outcome of fertility treatment. Self-identified lesbian women undergoing donor sperm IUI and IVF have similar pregnancy and live-birth rates as heterosexual women. Better evidence regarding patient demographics and comorbidities, underlying etiologies of subfertility, and assisted reproductive outcomes among women building families with other women is needed to optimize care.
Article
Study question: Are there differences in the clinical outcomes of IUI among different populational groups (heterosexual couples, single women and lesbian couples)? Summary answer: The outcome of donor IUI (D-IUI) is similar in all populational groups and better than that seen with autologous insemination. What is known already: A vast body of literature on clinical outcome is available for counselling heterosexual couples regarding decisions related to ART. The reproductive potential of single women, lesbian couples and heterosexual couples who need donor semen is assumed to be better, but there is a scarcity of data on their ART performance to actually confirm it. Study design, size, duration: In this retrospective multicentric cohort study, a total of 7228 IUI treatment cycles performed in 3807 patients between January 2013 and December 2016 in 13 private clinics belonging to the same reproductive medicine group in Spain were included. Patients with previous IUI attempts were excluded from the study. Only 1.9% of cycles were lost to follow-up. Participants/materials, setting, methods: A total of 5318 D-IUI cycles were performed in three different populational groups: heterosexual couples (D-HC, 1167 cycles), single women (SW, 2839 cycles) and lesbian couples (LC, 1312), while a total of 1910 autologous IUI cycles were performed in heterosexual couples (A-HC). This last one was considered the control group and was composed of cycles performed in couples with a male partner with sperm parameters equivalent to those requested from donors. In order to identify factors with an impact on clinical outcome, a multivariate logistic regression analysis was performed. Regarding live birth rate (LBR), mixed effect models were employed to control for the fact that different patients were submitted to different numbers of treatments. Main results and the role of chance: Parameters that were significant to the primary outcome (LBR) according to the multivariate analysis were the populational group (D-HC, SW, LC and A-HC) to which the patient belonged, female age and a diagnosis of low ovarian reserve. At the age range of good prognosis (≤37 years), LBR was similar in all groups that underwent D-IUI (18.8% for D-HC, 16.5% for SW and 17.6% for LC) but was significantly lower in the autologous IUI (A-HC) group (11%). For all these significant findings, the strength of the association was confirmed by P values <0.001. From 38 years of age on, no significant differences were observed among the populational groups studied, and for all of them, LBR was below 7% from 40 years of age on. Limitations, reasons for caution: To the best of our knowledge, a smoking habit was the only known factor with a potential effect on ART outcome that could not be controlled for, due to the unavailability of this information in a significant percentage of the clinical files studied. Our study was not capable of precisely quantifying the impact of a diagnosis of low ovarian reserve on the LBR of both IUI and D-IUI, due to the number of cycles performed in patients with such diagnosis (n = 231, 3.2% of the total). Wider implications of the findings: For the first time, a comparison among D-HC, SW, LC and A-HC was performed in a study with a robust sample size and controlling for potential sources of bias. There is now sound evidence that equivalent clinical outcome is seen in the three groups treated with donor semen (D-HC, SW and LC). Specifically, regarding the comparison between SW and LC, our findings rule out differences in LBR proposed by previous publications, with very similar clinical outcomes within the same age ranges. At age ranges of good prognosis (≤37 years), reproductive performance of D-IUI is significantly better than that seen in heterosexual couples undergoing autologous IUI, even when only cases of optimal sperm quality are considered in this last group. This finding is in agreement with the concept that, as a group, A-HC are more prone to have female factor infertility, even when their infertility assessment finds no contraindication to IUI. Age affects all these groups equally, with none of them reaching a 7% LBR after the age of 40 years. Our findings will be useful for the counselling of patients from the different populations studied here about ART strategies. Study funding/competing interest(s): None.
Chapter
As contemporary views on sexuality and gender become more inclusive, narratives around parenthood and reproduction are often separated from lesbian, gay, bisexual, transgender, and queer (LGBTQ+) human rights. Diverse historical accounts juxtiposed with legal restrictions provides a contradictory and limited scope of what makes a family. A global review of research, this chapter addresses how LGBTQ+ families counter stigma, discrimination, and erasure. Family-making takes places through a variety of methods, including but not limited to: surrogacy, adoption, and conception through ininsemination by a partner/co-parent. Health systems built on cisgender, heterosexual families as the ideal complicate access and acceptance; leaving no space for compassionate post-loss and miscarriage care. Exclusion is mirrored in adoption and family services, with LGBTQ+ parents having to navigate such systems unsupported. Sharing parental responsibilties and moving past gendered parenting roles, as done in LGBTQ+ parent-led homes, help to mitigates parental stress and offsets poorer mental health – shared experiences with discriminations leading to strong, supportive family units. As such, the mental, emotional, and physicial health of children raised in LGBTQ+ parented homes is better than or equal to the children of heterosexual peers. Further improvemants in access and quality of support are necessary.
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This bioessay reviews the impact of parental age, cause of infertility, embryo chromosomal anomalies, environmental and occupational exposures to xenobiotics, and protocol on assisted reproduction technology (ART) outcomes, particularly focusing on live-birth percentages per transfer. Special attention is paid to the effects of these factors on the mitochondrial, genetic, and epigenetic traits of gametes and embryos to determine the molecular/cellular mechanisms responsible for the relatively low percentages of live births reported year after year. The bias in age distribution of women attending fertility clinics –towards their late thirties and beyond– plus the high incidence of mosaicism found in pre-implantation embryos emerge as the two biggest contributors to low-birth rates. Reproductive aging of the parents and some causes of infertility are also associated with mitochondrial, genetic, and epigenetic alterations to gametes. ART treatments such as ovarian stimulation, gamete/embryo cryopreservation, oocyte in-vitro maturation, intracytoplasmic sperm injection, in vitro culture system, and embryo biopsy may induce further epigenetic changes in gametes and/or pre-implantation embryos. Exposure to numerous environmental chemicals, on the other hand, is linked to genetic and epigenetic defects in sperm. Whereas the selective transfer of euploid blastocysts may improve implantation and pregnancy percentages, especially in older women, it does not guarantee the total absence of mitochondrial and/or epigenetic defects in embryos. Thus, the presence of induced and/or inherited epigenetic disturbances in ART offspring are unlikely to be prevented even by replacing the whole cytoplasm of oocytes using nuclear genome transfer technology. Mol. Reprod. Dev. © 2014 Wiley Periodicals, Inc.
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Objective To identify the prognostic factors for pregnancy after intrauterine insemination with the husband's sperm (IUI-H). Design Retrospective study. Setting A single university medical center. Patient(s) 851 couples, for 2,019 IUI-H cycles. Intervention(s) After controlled ovarian stimulation, IUI-H performed 36 hours after ovulation triggering or 24 hours after a spontaneous luteinizing hormone (LH) surge. Main Outcome Measure(s) Clinical pregnancy rate per cycle (PR) and delivery rate per cycle (DR). Result(s) The overall PR was 14.8% and DR 10.8%. Higher PR and DR were observed for patients presenting with ovulation disorders (particularly polycystic ovary syndrome) or with male infertility. Secondary infertility in the woman appeared to be a positive prognostic factor as did a basal follicle-stimulating hormone (FSH) level ≤7 IU/L and ovulation triggering over spontaneous LH rise. The other parameters influencing the results were the women's age, the number of mature follicles obtained (≥2), the endometrial thickness (10–11 mm), and the number of progressive motile spermatozoa inseminated (>1 million). Conclusion(s) In women aged ≤38 years, IUI-H should be considered as an option, particularly in cases of female infertility from ovulation disorders, in cases of a normal ovarian reserve, in cases of secondary infertility, or when ≥1 million progressive sperm are inseminated. Bifollicular stimulation is required. In other cases, in vitro fertilization should be discussed as the first-line treatment.