2 2. Infertility and Its Economic and Psychological Impacts Infertility is deﬁned as failure to achieve pregnancy for one year or more without use of contraception during the childbearing period and aﬀects approximately 10–15% of couples [5]. In 1995, The National Survey of Family Growth reported that 9.3 million women between 15– 44 years (15% of women of reproductive age) made use of infertility services in the United States. These services included medical advice, testing for both couples, drugs for ovulation induction, corrective surgery for tubal blockage, and assisted reproductive technologies (ARTs) [6]. The costs of infertility evaluation and therapy were evaluated in a study conducted by Stovall et al. [7]. They found that the costs of infertility services ranged from 0.36 to 1.03% of a total health care plan with an average of 0.8%. In a 3-year period, they found that infertility cost was $680 921 of $86 445 642 total health care plan costs. In addition to its economic costs, infertility has a major psychological impact. Oddens et al. reported that infertile women had depressive and anxiety symptoms four times more frequently than fertile women [8], and the rate is comparable to women with cancer and coronary heart disease [9]. The presence of such psychological disorders may have a negative impact on infertility treatment outcomes, as it was reported that IVF success rates in the ﬁrst 5 cycles may be lower in depressed women compared to the nondepressed [10]. 3. Limitations of Assisted Reproductive Technologies In 2001 in the United States, 108 130 ART cycles were carried out in 385 programs, with 79 042 cycles being IVF [11]. In 2003 in Europe, 365 103 ART cycles were accomplished in 1008 clinics, with 132 932 cycles being IVF [12]. Despite this increase in the use of these treatment modalities, they are still costly, invasive, and associated with drawbacks. In the year 2001, the median cost of IVF in the US was extrapolated to be $9 226 per cycle and $56 419 per delivery. Outside the US, this cost was calculated to be $3 531 per cycle and $20 522 per delivery [13]. The high cost of IVF deepens on the gap between the number of IVF cycles performed and the treatment needs of infertile couples. In addition to its costs, the use of IVF is associated with other undesirable outcomes. These include preterm delivery, leading to increased risk of newborn prematurity and its concomitant costs and morbidity, and increased rates of multiple gestations [14]. In the US, in the year 2003, 48 756 infants were born from ARTs, accounting for 1% of all births. Fifty-one percent of this number resulted from multiple gestations. Furthermore, the incidence of low birth weight and preterm delivery among singleton infants born from ARTs were 9% and 15%, respectively, while low birth weight occurred in 94% among triplets and higher order multiple gestations [15]. In a meta-analysis to assess the perinatal outcome in singletons following IVF [16], Jackson Obstetrics and Gynecology International et al. reported increased fetal risks of preterm birth, low and very low birth weights, small for gestational age, neonatal intensive care unit admissions, stillbirth, neonatal mortality, and cerebral palsy as well as increased maternal risks of pre-eclampsia, placenta previa, gestational diabetes, and caesarean delivery. Furthermore, there may be an increased incidence of major birth defects (renal and musculoskeletal) and autosomal reciprocal-balanced translocations among infants born after IVF/ICSI compared to naturally conceived infants [17, 18]. 4. Limitations of IUI The limitations of IUI are few. They included the potential risk of infection from uterine catheterization and injection of the semen specimen. However, this risk has been reported to be 0.01–0.2%. In addition, ectopic pregnancies and spon- taneous miscarriages may occur, which is not diﬀerent from other infertility treatment modalities [19]. The production of antisperm antibodies is another hypothetical drawback of the use of IUI. The incidence of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS) with IUI may occur and is related to the use of ovarian stimulation with IUI. The risk of OHSS may be decreased by use of low-dose drug regimens, close monitoring, and strict cycle cancellation criteria. Regarding the perinatal outcomes of IUI conceptions, Gaudoin et al. reported in a retrospective cohort study that ovulation induction combined with IUI was associated with increased risk of preterm birth and low birth weight [20]. However, other studies did not describe such associations [21, 22]. 5. Effectiveness of IUI The pregnancy rate of IUI is reported to 10–20% per patient, but the reported rates range from as low as 5% to as high as 70% [23]. Based on the etiology of infertility, the highest rates were reported when IUI was used in patients with anovulation who were undergoing ovulation induction therapy at the time of the IUI treatment, male factor infertility, and unexplained infertility. In patients with endometriosis, the pregnancy rates were the lowest [24]. The number of mature follicles (17 mm in diameter or more) is another prognostic factor in IUI success, where the presence of 3-4 mature follicles was associated with higher pregnancy rates and a lower incidence of high-order multiple pregnancies [25]. Other prognostic factors included female age, infertility duration and amount of motile sperm [26]. The cost eﬀectiveness of IUI has been studied. In a retrospective cohort study [27], Van Voorhis et al. reported $8 674 as the cost per delivery for IUI alone, $7 808 for clomiphene combined with IUI, $10 282 for human menopausal gonadotropin (hMG) combined with IUI and $43 138 for IVF. The authors supported the use of IUI (any modality) as being cost eﬀective, before ART, for infertile couples with patent tubes, female age 38 years or less, and a sperm count of 10 × 106 motile spermatozoa in a post wash