Risk of pelvic inflammatory disease after intrauterine insemination: a systematic review
The aim of this study was to ascertain the incidence of pelvic inflammatory disease (PID) after intrauterine insemination (IUI). A systematic review was conducted using three different approaches: a search of IUI registries; a search of published meta-analyses; and a search of prospective randomized trials. Search terms were ‘IUI’, ‘complications’, ‘infection’ and ‘PID’. Two IUI registers were identified that met the inclusion criteria, totalling 365,874 cycles, with 57 PID cases being reported. The post-IUI PID rate was 0.16/1000 (95% CI 0.2 to 0.3/1000). The frequency was higher in husband sperm cycles (0.21/1000) (28/135,839) than in donor sperm cycles (0.03/1000) (1/33,712) (P < 0.05; OR 6.95). Nineteen meta-analyses were retrieved, which included 156 trials, totalling 43,048 cycles, with no PID case being reported. Seventeen prospective clinical trials published between 2013 and 2014 were identified, totalling 4968 cycles; no PID case was reported. The reported rate of post-IUI clinical PID is low (0.16/1000), about 40% higher than reported in the general population of women during their reproductive life. No antibiotic prophylaxis should be recommended unless there is an associated risk factor.
Intrauterine insemination (IUI) is a widely used procedure. According to the European Society of Human Reproduction and Embryology register, more than 200,000 cycles are carried out in Europe every year, and about 175,000 of them correspond to the sperm of the husband or partner (European IVF-Monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE) et al., 2016European IVF-Monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE) et al., 2016). Common complications of IUI include multiple pregnancy and ovarian hyperstimulation syndrome. Pelvic inflammatory disease (PID) has been reported as a rare complication of IUI, but no data about its expected frequency are available.
Severe complications are associated with PID, and some of them are especially relevant in women with unfulfilled fertility, such as tubal damage, tubo-ovarian abscess and even ovariectomy. About 15% of PID occurs after procedures that break the cervical mucus barrier (Rock, Jones, 2003, Terao et al, 2014, Weledji, Elong, 2013). On occasions, PID may develop after certain procedures, such as hysterosalpingography, hysteroscopy, endometrial biopsy, oocyte recovery or even embryo transfer (Pereira et al., 2016Pereira et al., 2016). Antibiotic prophylaxis, however, is not recommended in any of these procedures unless there is a concomitant risk factor (Pereira et al, 2016, Van Eyk, van Schalkwyk, 2012).
In some cases of IUI, the introduction of the catheter through the cervical canal and the release of washed sperm could prompt the ascension and spread of cervical microorganisms into the uterus and the tubes. It is well known that ascension of microorganisms is the main mechanism of PID genesis (Paavonen et al., 2008Paavonen et al., 2008).
Some case reports on the occurrence of PID after IUI have been published (Kolb et al, 1994, Moradan, 2009, Sable et al, 1993). In a literature review, Sacks and Simon (1991))Sacks and Simon (1991) concluded that, after IUI, PID frequency was 6.8/1000; however, Speroff et al. (1999))Speroff et al. (1999) cite a frequency close to 1/500. The clinical impression, however, is that the frequency is much lower.
The occurrence of PID after IUI is a rare complication, and no reliable data on its frequency have been published; therefore, it is difficult to give exact information to patients, and to make decisions about prophylactic antibiotic therapy.
The aim of our study was to determine the frequency of PID after IUI on the basis of a literature search of large case studies, using three complementary analyses: data from IUI registers where PID is considered; meta-analyses of IUI reporting on complications; and all IUI prospective studies published between 2013 and 2014. Finally, we compare them with our centre’s IUI complication register.