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Risk of bias: review authors' judgements about each risk domain presented as percentages across all included studies.
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Figure 1

Risk of bias: review authors' judgements about each risk domain presented as percentages across all included studies.

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Risk domains: review authors' judgements about each potential risk of bias item for each included study.
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Figure 2

Risk domains: review authors' judgements about each potential risk of bias item for each included study.

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Forest plot of comparison: 1 Swim‐up versus gradient technique; fresh semen, outcome: 1.1 Pregnancy rate per couple.
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Figure 3

Forest plot of comparison: 1 Swim‐up versus gradient technique; fresh semen, outcome: 1.1 Pregnancy rate per couple.

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Forest plot of comparison: 1 Swim‐up versus gradient technique; fresh semen, outcome: 1.2 Miscarriage rate per couple.
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Figure 4

Forest plot of comparison: 1 Swim‐up versus gradient technique; fresh semen, outcome: 1.2 Miscarriage rate per couple.

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Forest plot of comparison: 2 Swim‐up versus wash and centrifugation; fresh semen, outcome: 2.1 Pregnancy rate per couple.
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Figure 5

Forest plot of comparison: 2 Swim‐up versus wash and centrifugation; fresh semen, outcome: 2.1 Pregnancy rate per couple.

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Forest plot of comparison: 3 Gradient technique versus wash and centrifugation; fresh semen, outcome: 3.1 Pregnancy rate per couple.
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Figure 6

Forest plot of comparison: 3 Gradient technique versus wash and centrifugation; fresh semen, outcome: 3.1 Pregnancy rate per couple.

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Comparison 1 Swim‐up versus gradient technique, fresh semen, Outcome 1 Pregnancy rate per couple.
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Analysis 1.1

Comparison 1 Swim‐up versus gradient technique, fresh semen, Outcome 1 Pregnancy rate per couple.

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Comparison 1 Swim‐up versus gradient technique, fresh semen, Outcome 2 Miscarriage rate per couple.
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Analysis 1.2

Comparison 1 Swim‐up versus gradient technique, fresh semen, Outcome 2 Miscarriage rate per couple.

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Comparison 1 Swim‐up versus gradient technique, fresh semen, Outcome 3 Multiple pregnancy rate per couple.
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Analysis 1.3

Comparison 1 Swim‐up versus gradient technique, fresh semen, Outcome 3 Multiple pregnancy rate per couple.

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Comparison 2 Swim‐up versus wash and centrifugation, fresh semen, Outcome 1 Pregnancy rate per couple.
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Analysis 2.1

Comparison 2 Swim‐up versus wash and centrifugation, fresh semen, Outcome 1 Pregnancy rate per couple.

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Comparison 2 Swim‐up versus wash and centrifugation, fresh semen, Outcome 2 Miscarriage rate per couple.
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Analysis 2.2

Comparison 2 Swim‐up versus wash and centrifugation, fresh semen, Outcome 2 Miscarriage rate per couple.

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Comparison 2 Swim‐up versus wash and centrifugation, fresh semen, Outcome 3 Multiple pregnancy rate per couple.
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Analysis 2.3

Comparison 2 Swim‐up versus wash and centrifugation, fresh semen, Outcome 3 Multiple pregnancy rate per couple.

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Comparison 3 Gradient technique versus wash and centrifugation, fresh semen, Outcome 1 Pregnancy rate per couple.
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Analysis 3.1

Comparison 3 Gradient technique versus wash and centrifugation, fresh semen, Outcome 1 Pregnancy rate per couple.

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Comparison 3 Gradient technique versus wash and centrifugation, fresh semen, Outcome 2 Miscarriage rate per couple.
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Analysis 3.2

Comparison 3 Gradient technique versus wash and centrifugation, fresh semen, Outcome 2 Miscarriage rate per couple.

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Comparison 3 Gradient technique versus wash and centrifugation, fresh semen, Outcome 3 Multiple pregnancy rate per couple.
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Analysis 3.3

Comparison 3 Gradient technique versus wash and centrifugation, fresh semen, Outcome 3 Multiple pregnancy rate per couple.

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Summary of findings for the main comparison. Swim‐up technique compared to gradient technique for undergoing intrauterine insemination

Swim‐up technique compared to gradient technique for undergoing intrauterine insemination

Patient or population: patients undergoing intrauterine insemination (fresh semen)
Intervention: swim‐up technique
Comparison: gradient technique

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Gradient technique

Swim‐up technique

Pregnancy rate per couple

215 per 1000

301 per 1000
(169 to 477)

OR 1.57
(0.74 to 3.32)

147
(3 studies)

⊕⊝⊝⊝
very low1,2

Miscarriage rate per couple

67 per 1000

9 per 1000
(1 to 87)

OR 0.13
(0.01 to 1.33)

107
(2 studies)

⊕⊕⊕⊝
moderate3

Multiple pregnancy rate per couple

See comment

See comment

Not estimable

25
(1 study)

⊕⊕⊕⊝
moderate4

There were no events recorded in either group

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Two of the trials did not use blinding, nor was there adequate explanation for randomisation or allocation concealment or attrition in these two studies.
2 I square statistic was 64% indicating significant heterogeneity
3 One of the trials failed to provide adequate details on randomisation, allocation concealment, and attrition. There was no evidence of blinding.
4 Evidence based on a single trial

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Summary of findings for the main comparison. Swim‐up technique compared to gradient technique for undergoing intrauterine insemination
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Summary of findings 2. Swim‐up technique compared to wash and centrifugation for undergoing intrauterine insemination

Swim‐up technique compared to wash and centrifugation for undergoing intrauterine insemination

Patient or population: patients undergoing intrauterine insemination (fresh semen)
Intervention: swim‐up technique
Comparison: wash and centrifugation

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Wash and centrifugation

Swim‐up technique

Pregnancy rate per couple

381 per 1000

201 per 1000
(85 to 404)

OR 0.41
(0.15 to 1.1)

78
(2 studies)

⊕⊕⊝⊝
low1,2

Miscarriage rate per couple

See comment

See comment

Not estimable

20
(1 study)

⊕⊕⊕⊝
moderate3

There were no events in either group

Multiple pregnancy rate per couple

62 per 1000

13 per 1000
(0 to 424)

OR 0.2
(0 to 11.06)

26
(1 study)

⊕⊕⊝⊝
low3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the trials did not conceal allocation and there was no blinding
2 I square statistic was 55% indicating significant heterogeneity
3 Evidence based on a single trial
4 Wide confidence intervals indicate some imprecision

Figuras y tablas -
Summary of findings 2. Swim‐up technique compared to wash and centrifugation for undergoing intrauterine insemination
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Summary of findings 3. Gradient technique compared to wash and centrifugation for undergoing intrauterine insemination

Gradient technique compared to Wash and centrifugation for undergoing intrauterine insemination

Patient or population: patients with undergoing intrauterine insemination (fresh semen)
Intervention: gradient technique
Comparison: wash and centrifugation

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Wash and centrifugation

Gradient technique

Pregnancy rate per couple

133 per 1000

213 per 1000
(81 to 456)

OR 1.76
(0.57 to 5.44)

94
(2 studies)

⊕⊕⊝⊝
low1,2

Miscarriage rate per couple

0 per 1000

0 per 1000
(0 to 0)

OR 8.48
(0.51 to 142.39)

31
(1 study)

⊕⊕⊝⊝
low3,4

Multiple pregnancy rate per couple

62 per 1000

9 per 1000
(0 to 327)

OR 0.14
(0 to 7.28)

31
(1 study)

⊕⊕⊝⊝
low3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the two trials did not provide adequate details on randomisation or allocation concealment and did not use blinding.
2 I square statistic was 52% indicating some heterogeneity.
3 Wide confidence intervals were indicative of a lack of precision
4 Evidence is based on a single trial

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Summary of findings 3. Gradient technique compared to wash and centrifugation for undergoing intrauterine insemination
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Table 1. Characteristics of cross‐over RCTs excluded from meta‐analysis

Study ID

Allocation Score

Methods

Participants

Interventions

Outcomes

Carrell 1998

B

Stated random, but no details. Design: cross‐over, multi‐centre. Concealment of allocation, blinding, number of drop‐outs or cancelled cycles, intention‐to‐ treat analysis, power calculation: all not stated.

363 women: 558 cycles in the 3 methods of interest. Age women, duration subfertility: not stated. Cause: unexplained/ (fe)male related disorders. Exclusion criteria: oligoasthenozoospermic semen samples after preparation. Inclusion criteria: not stated.

3 preparation techniques (out of 5 described). 1) Sperm wash: 8‐10 ml. medium (Ham's F‐10), 10 min. 400x g centrifug. Supernatant decanted, pellet resusp. 2) Swim‐up: 2x washed, resusp. Medium layered on top. Incubation 1h. Top removed. 3) Gradient: 1x wash+ resusp. Percoll, (35%/ 90%).15 min 400x g centrifug. 90% layer washed. Single IUI. 2.5 ± 0.3 inseminations per women. 124 women: 50‐200 mg. CC day 5‐9 or no COH. 239 women: gonadotropin/ hCG.

Pregnancy rate (PR)/ cycle, Miscarriage rate (MR)/ pregnancy, Live birth rate (LBR)/ cycle

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Table 1. Characteristics of cross‐over RCTs excluded from meta‐analysis
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Table 2. Results from cross‐over RCTs excluded from meta‐analysis

Study ID

Sample Size

Gradient technique

Swim‐up

Wash and centrifuge

Conclusion

Statistical analysis

Carrell 1998

558 cycles

PR/ cycle: 16.1% (33/204), LBR/ cycle: 12.7% (26/204), MR/ pregnancy: 21.2% (7/33)

PR/ cycle: 14.7% (29/197), LBR/ cycle: 13.2 (26/197), MR/ pregnancy: 10.3 % (3/29)

PR/ cycle: 8.9% (14/157), LBR/ cycle: 7.0% (11/157), MR/ pregnancy: 21.4% (3/14)

PR/cycle wash‐method significantly lower than Swim‐up/ Percoll (P<0.05), LBR/cycle wash‐method significantly lower than Swim‐up/ Percoll (P<0.05). No other significant differences.

PR/cycle and MR/pregnancy: X2 analysis and Fisher's exact test. Statistical significance P<0.05.

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Table 2. Results from cross‐over RCTs excluded from meta‐analysis
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Comparison 1. Swim‐up versus gradient technique, fresh semen

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pregnancy rate per couple Show forest plot

3

147

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.57 [0.74, 3.32]

2 Miscarriage rate per couple Show forest plot

2

107

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.13 [0.01, 1.33]

3 Multiple pregnancy rate per couple Show forest plot

1

25

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.0 [0.0, 0.0]
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Comparison 1. Swim‐up versus gradient technique, fresh semen
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Comparison 2. Swim‐up versus wash and centrifugation, fresh semen

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pregnancy rate per couple Show forest plot

2

78

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.41 [0.15, 1.10]

2 Miscarriage rate per couple Show forest plot

1

20

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Multiple pregnancy rate per couple Show forest plot

1

26

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.20 [0.00, 11.06]
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Comparison 2. Swim‐up versus wash and centrifugation, fresh semen
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Comparison 3. Gradient technique versus wash and centrifugation, fresh semen

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pregnancy rate per couple Show forest plot

2

94

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.76 [0.57, 5.44]

2 Miscarriage rate per couple Show forest plot

1

31

Peto Odds Ratio (Peto, Fixed, 95% CI)

8.48 [0.51, 142.39]

3 Multiple pregnancy rate per couple Show forest plot

1

31

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.14 [0.00, 7.28]
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Comparison 3. Gradient technique versus wash and centrifugation, fresh semen
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