Correspondence
Efficacy of Superovulation and Intrauterine Insemination in the Treatment of Infertility
N Engl J Med 1999; 341:128-129July 8, 1999
- Article
To the Editor:
In their report on the treatment of infertility with follicle-stimulating hormone and intrauterine insemination, Guzick et al. (Jan. 21 issue)1 did not state in their discussion that a more cost effective and safer method, administration of clomiphene citrate and intrauterine insemination, is available. In 1998 Guzick et al., in a meta-analysis of studies of treatments for unexplained infertility, concluded, “Clomiphene citrate + IUI [intrauterine insemination] is a cost-effective treatment for unexplained infertility. If this treatment fails, [human menopausal gonado-tropins] + IUI and assisted reproduction are efficacious therapeutic options.”2 The high incidence of multiple pregnancy among the women who received follicle-stimulating hormone in the current study and the occurrence of hyperstimulation requiring the hospitalization of six women make it evident that follicle-stimulating hormone plus intrauterine insemination is also less safe than clomiphene citrate plus intrauterine insemination.
2 ReferencesRichard Dickey, M.D., Ph.D.
Sissy Marascalco Sartor, M.D.
Roman Pryzak, Ph.D.
Fertility Institute of New Orleans, New Orleans, LA 701281
Guzick DS ,Carson SA ,Coutifaris C , et al. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. N Engl J Med 1999;340:177-183
Full Text | Web of Science | Medline2
Guzick DS ,Sullivan MW ,Adamson GD , et al. Efficacy of treatment for unexplained infertility. Fertil Steril 1998;70:207-213
CrossRef | Web of Science | Medline
To the Editor:
My comment concerns the terminology used in describing the couples studied by Guzick et al. and also used by te Velde and Cohlen in their editorial.1 Throughout both, “infertility” is the only term that is used. In common language, infertility is synonymous with sterility2 (i.e., the inability to initiate pregnancy). However, all we know about the couples in the trial is that they probably had reduced fertility, as compared with the general population. Thus, the couples had unexplained subfertility or, in the case of some of the men, male subfertility.
These couples often still have reasonable prospects of achieving pregnancy with no treatment.3,4 Thus, the use of the term infertility is inappropriate, can cause confusion, and can easily induce feelings of panic and hopelessness among the couples concerned, who will subsequently embrace any treatment that might cure their “infertility.”
4 ReferencesJ.D.F. Habbema, Ph.D.
Erasmus University Rotterdam, 3000 DR Rotterdam, the Netherlands1
te Velde ER ,Cohlen BJ . The management of infertility. N Engl J Med 1999;340:224-226
Full Text | Web of Science | Medline2
Sinclair J, ed. Collins Cobuild English language dictionary. London: Collins, 1988.
3
Collins JA ,Burrow EA ,Wilan AR . The prognosis for live birth among untreated infertile couples. Fertil Steril 1995;64:22-28
Web of Science | Medline4
Eimers JM ,te Velde ER ,Gerritse R ,Vogelzang ET ,Looman CW ,Habbema JD . The prediction of the chance to conceive in subfertile couples. Fertil Steril 1994;61:44-52
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree that clomiphene citrate plus intrauterine insemination is an efficacious treatment for unexplained infertility. Our study focused on follicle-stimulating hormone and human chorionic gonadotropin because of their greater costs and risks and wider use. It may be reasonable to begin the treatment of couples with unexplained infertility with clomiphene citrate. This does not preclude the subsequent administration of gonadotropins, the efficacy of which is supported by the results of our trial.
In the United States, infertility is usually defined as the inability to conceive after one year of unprotected intercourse.1 Nonetheless, Dr. Habbema raises a good point. In other countries and also in lay terms, infertility is synonymous with sterility.2 However, for this same audience (and according to the Oxford English Dictionary), the term “subfertility” is not a word.2 Certainly, as physicians, we must be aware of such subtleties of language and support our patients from every culture and country.
2 ReferencesSandra Ann Carson, M.D.
Baylor College of Medicine, Houston, TX 77030David S. Guzick, M.D., Ph.D.
University of Rochester, Rochester, NY 14642Donna L. Vogel, M.D., Ph.D.
National Institutes of Health, Bethesda, MD 20892Author/Editor Response
We agree with Dr. Habbema that the term “infertility” commonly has the same meaning as sterility, whereas in reproductive medicine it is often defined as a failure to conceive within one year. To prevent confusion and misunderstanding, doctors involved in reproductive medicine should use a concept that is unequivocally clear to patients. The terms “sterility” and “complete infertility” should be reserved exclusively for couples who have no chance of conceiving and the terms “infertility” and “relative infertility” used for couples who still have a chance, albeit small, of conceiving.1 Relative infertility is a contradiction in terms and alien to common language. Moreover, sterility is relatively rare and difficult to define. Even in cases in which there is a convincing explanation for the continuous absence of conception — for example, the presence of bilateral blocked fallopian tubes — pregnancy occurring later has been described. Some avoid the term infertility and use only “subfertility,”2 defined as a failure to conceive within a 12-month period. This terminology is the best solution to the problem posed by Dr. Habbema, because it is an unequivocal concept, both in common language and in reproductive medicine.
2 ReferencesEgbert R. te Velde, M.D., Ph.D.
Bernard J. Cohlen, M.D., Ph.D.
University Hospital Utrecht, 3508 GA Utrecht, the Netherlands1
Jansen RP . Elusive fertility: fecundability and assisted conception in perspective. Fertil Steril 1995;64:252-254
Web of Science | Medline2
Greenhall E ,Vessey M . The prevalence of subfertility: a review of the current confusion and a report of two new studies. Fertil Steril 1990;54:978-983
Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Y. Soffer. (2000) Les inséminations intra-utérines. Andrologie 10:4, 443-451
CrossRef
