4 and clomiphene citrate (CC) were compared for ovulation induction with IUI in couples with unexplained and male factor infertility, the cumulative pregnancy rate was 38% for CC-IUI group versus 34.3% for the rFSH-IUI group [43]. Recently Cantineau and Cohlen performed a Cochrane review to evaluate diﬀerent ovarian stimulation protocols (antiestrogens, aromatase inhibitors, and gonadotropins with or without GnRH agonists/antagonists) [44]. All pub- lished randomized controlled trials (RCTs) comparing dif- ferent stimulation protocols before IUI were searched in the Menstrual Disorders and Subfertility group’s Central register of the Controlled Trials, Medline, and EMBASE. 81 studies were identiﬁed, but only 43 trials met the inclusion criteria. Of the diﬀerent comparisons done in this review, letrozole was not more eﬀective than CC (OR 1.2, 95% CI: 0.64–2.1). The analysis also revealed that gonadotropins, in low-dose regimens (50–75 IU), were the most eﬀective agents when ovarian stimulation was combined with IUI. Although less eﬀective than gonadotropins, antiestrogens were more cost eﬀective in IUI therapy. Neither a higher dosage (>75 IU gonadotropins) nor the addition of GnRH agonists was more eﬀective. Conversely, the higher dosage and the GnRH agonists were associated with increased costs and risks of multiple gestations and of OHSS. A systematic review by Costello assessed the eﬀectiveness of CC and IUI in the treatment of ovulatory infertility [45]. Seven RCTs were included in this review. The meta-analysis of this review showed a cycle pregnancy rate of 14.3% for CC combined with IUI versus 6.4% for natural cycle IUI. Considerations in Technology-Limited Settings . The evidence reviewed suggests that oral clomiphene therapy combined with IUI or natural cycle IUI is satisfactory ﬁrst-line choices for treatment of unexplained and male infertility in low-technology settings. The combination of IUI and controlled ovarian hyperstimulation may result in a relatively higher therapeutic pregnancy rate for unexplained and for male infertility. Gonadotropins are the controlled ovarian hyperstimulation agents that result in the highest rates of pregnancy. However, the costs associated with these drugs are higher, and the serum steroid measurements and ultrasonographic monitoring require higher levels of technological capabilities. 7. Semen Parameters and the Use of IUI The WHO criteria for normal semen parameters are widely used [46]. In the system, an abnormal semen count is deﬁned as deviations from the normal criteria on two con- secutive semen analyses [46]. Studies have examined semen parameters, like motile sperm concentration and normal sperm morphology, in relation to IUI outcome (Table 1). In Table 1, four inferences could be made: most of the studies are retrospective, the number of insemination cycles is fewer in the prospective studies, all but one study used the inseminated motile sperm count after sperm preparation and Obstetrics and Gynecology International the studies reported on diﬀerent outcome measurements. In spite of the limitations outlined above, it may be deduced that reasonable IUI success rates can still be obtained in cases of severe semen defects (normal morphology 4% or less and inseminated sperm count as low as one million). This supports the need for large well-designed prospective studies using standard outcomes. Regarding sperm concentration, Ombelet et al. in a retrospective study found that when inseminated motile sperm count was > 1 × 106, clomiphene-IUI resulted in a baby take-home rate of 21–25% after 3 cycles [47]. Even when inseminated motile sperm count was < 1 × 106 and the normal sperm morphology >4%, clomiphene-IUI remained a treatment choice that resulted in pregnancies. In a retrospective analysis of 3 479 IUI cycles conducted for 1039 infertile couples [48], Van Voorhis et al. found that a total motile sperm count per specimen of less than 10 million was associated with lower pregnancy rates. On the other hand, a total motile sperm count above 10 million did not produce a signiﬁcant increase in IUI pregnancy rates. Cohlen et al. deﬁned a total motile sperm count per ejaculate between 5 and 10 × 106 to be a severe semen defect [49]. They reported a pregnancy rate per IUI cycle of 12% for couples with that count. Wainer et al. reported on the number of motile sperm inseminated [50] and found a clinical pregnancy rate per cycle of 3.13% when the number of motile sperm inseminated was < 1 × 106. When the number of motile sperm inseminated was between 5 and 10 × 106, the clinical pregnancy rate per cycle was 14%. Miller et al. reported a cutoﬀ point for number of motile sperm inseminated after sperm preparation as 10 × 106 [51]. Berg et al. reported successful pregnancies in patients after controlled ovarian stimulations in IUI preparations with motile sperm counts as low as >0.8 × 106 [52]. Normal sperm morphology as a predictor of IUI success has been examined. After controlling for sperm concentra- tion and motility, Lee et al. found that the normal sperm morphology, using Kruger’s strict criteria [53], more strongly predicted IUI outcome [54]. They reported pregnancy rates per cycle of 3.8% in couples with <4% of Kruger’s strict criteria normal morphology, 18.5% for Kruger’s strict criteria normal morphology of 4–9% and 29.9% when Kruger’s strict criteria normal morphology was above 9% [54]. These results were similar to those reported in a study by Hauser et al. [55], where CC-IUI resulted in a pregnancy rates per couple of 11.1% when normal morphology by strict criteria was less than 4%, 36.1% for normal morphology of 4–14% and 50% when normal morphology was above 14%. The link between sperm motility and IUI success was addressed in several studies. Brieﬂy, in these studies, total motile sperm of 30–50% before sperm preparation was found to be associated with positive IUI outcomes [54, 56, 57]. Considerations in Technology-Limited Settings. The evidence reviewed suggests that IUI may be oﬀered to couples with male factor infertility, in a low technology setting, if the total motile sperm count is more than 5 million per specimen.