title: Ovarian stimulation and intrauterine insemination at the quarter centennial: implications for the multiple births epidemic.
abstract: Ovarian stimulation and intrauterine insemination (OS/IUI), a mainstay of current infertility therapy and a common antecedent to IVF, is a significant driver of the multiple births epidemic. Redress of this challenge, now marking its quarter centennial, will require a rethinking of current practice patterns. Herein we explore prospects for prevention, mitigation, and eventual resolution. We conclude that the multiple births attributable to OS/IUI may not be entirely preventable but that the outlook for their mitigation is promising, if in need of solidification. Specifically, we observe that low-dose (≤ 75 IU) gondotropin, clomiphene, and especially off-label letrozole regimens outperform high-dose (≥ 150 IU) gonadotropin counterparts in the gestational plurality category while maintaining comparable per-cycle pregnancy rates. Accordingly we recommend that, subject to appropriate exceptions, high-dose gonadotropin regimens be used sparingly and that whenever possible they be replaced with emerging alternatives. Finally, we posit that OS/IUI is not likely to be superseded by IVF absent further commoditization and thus greater affordability.
authors.affiliation: Shady Grove Fertility, Baltimore, Maryland, USA.
authors.forename: Howard D
authors.initials: HD
authors.lastname: McClamrock
authors.forename: Howard W
authors.initials: HW
authors.lastname: Jones
authors.forename: Eli Y
authors.initials: EY
authors.lastname: Adashi
mesh_terms: D058872:Epidemics; D005260:Female; D005300:Fertility Agents, Female / Q000008:administration & dosage; D006062:Gonadotropins / Q000008:administration & dosage; D006801:Humans; D007246:Infertility / Q000503:physiopathology / Q000628:therapy*; D007315:Insemination, Artificial / Q000009:adverse effects*; D009099:Multiple Birth Offspring / Q000706:statistics & numerical data; D010062:Ovulation Induction / Q000009:adverse effects*; D011247:Pregnancy; D011272:Pregnancy, Multiple / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D013480:Superovulation; D016896:Treatment Outcome
chemical_list: D005300:Fertility Agents, Female; D006062:Gonadotropins