Obstetrics and Gynecology International Table 2: Sperm preparation methods. Author Year Design (prospective or retrospective) Number of infertile patients Number of insemination cycles Carrell et al. 1998 Prospective 363 Dodson et al. 1998 Prospective Morshedi et al. 2003 Prospective Lan et al. 2004 Prospective Ren et al. 2004 Prospective PR: Pregnancy rate; CF: Cycle fecundity; NA: Not available. 80 311 140 898 153 676 317 Method of preparation Sperm wash -Swim-up -Swim-down -Percoll density gradient -Sperm refriger- ation/heparin incubation Double cenrifugation -Swim-up -Percoll density gradient Simple wash -Density gradient Swim-up -Percoll density gradient -Wang’s tube method Albumin -Puresperm -Swim-up -Percoll density gradient 7 IUI outcome PR 8.9% 14.7% 7.7% 16.1% 11% CF 15% 14% 20% PR 11.6% 14.3% PR 15% 20% 45% PR 12.5% 7.4% 9.6% 12.7% studies were included in the review. The pooled outcomes of the studies were a pregnancy rate per cycle of 14.9% for double IUIs versus 11.4% for a single IUI. This diﬀerence was statistically insigniﬁcant. The Cochrane review, by Cantineau et al., followed the same search strategies and data analyses as mentioned previously [81]. From the 30 studies retrieved, 13 were found to provide data comparing single versus double inseminations. Only 3 RCTs were included in the review, the results of 2 of them were pooled for meta- analysis. The authors concluded that there was no evidence that double inseminations give rise to higher live birth rates in infertile couples compared to single inseminations (OR 1.45, CI: 0.78–2.7). The NICE recommendation is for a single insemination when oﬀering IUI as therapy [39]. Considerations in Technology-Limited Settings. The evidence suggests that single IUI insemination per ovulatory cycle should be considered. Published evidence does not support that two IUI in a single cycle results in a higher rate of pregnancy. A single insemination will be less costly, with similar pregnancy outcomes. 11. Number of Insemination Cycles Some studies report six treatment cycles [29, 60, 78], while others report four cycles [35, 82] as the number of cycles of treatment with IUIs. One study reported a cumulative probability of pregnancy of 38.2% for 6 treatment cycles and 49.5% for 10 treatment cycles [52]. One of the six- cycle studies, by Morshedi et al., reported that 88% of the pregnancies occurred in the ﬁrst 3 cycles [60]. However, a Cochrane review and the NICE guidelines support using IUI as treatment for up to 6 cycles [32, 83]. The NICE reported, with level I evidence, that the use of up to 6 cycles on IUI increased the chance of pregnancy for couples with mild male-factor and unexplained infertility and minimal to mild endometriosis. The Cochrane reviewers concluded that most pregnancies occurred during the ﬁrst 3 to 6 IUIs treatment cycles. Considerations in Technology-Limited Settings. The evidence suggests performing a minimum of three IUI treatment cycles and a maximum of six IUI treatment cycles in technology-limited setting.