**3. Super ovulation and intra-uterine insemination (IUI)**

Super ovulation and IUI involves stimulating the ovary with ovulation induction agents with the aim to produce two follicles, then with ovulation trigger performing IUI to allow the sperm to bypass the cervical environment. It is usually performed in patients with unexplained subfertility or mild male factor subfertility. Consequently, the purpose of the treatment is to increase the chance of a successful pregnancy by increasing the number of oocytes ovulated and the availability of sperm.

Given it is used in women that are already ovulating, prudent use of ovulation induction agents is imperative and careful monitoring of the cycle with ultrasound and oestrogen levels is important, as in ovulation induction, to prevent multiple pregnancy and higher order multiple pregnancy. Unlike ovulation induction, where the aim is to produce a single dominant follicle, super-ovulation is aimed at producing two follicles, with well controlled cycles accepting up to three follicles, but certainly no more. The reason is in this situation there is a potentially as yet unrecognised factor limiting conception, whereas in standard ovulation induction treatment for the anovulatory woman, it is only the absence of ovulation that is limiting conception, hence when that is overcome the woman should conceive. Once four follicles are present there is no increase in the live birth rate, but a significant increase in the multiple pregnancy and higher order multiple pregnancy rate [21].

As the aim is to produce more than one follicle the risk of multiple pregnancy is high, higher than that is seen with IVF or ovulation induction. Overall rates of multiple pregnancy are around 14% in well controlled cycles, involving cancellation when more than three follicles are identified [24]. This is higher than is seen with IVF cycles, even in well controlled ovarian hyperstimulation protocols. Like ovulation induction the discussion regarding switching to an IVF treatment course, or cancellation of the cycle is required to be had with the patient prior to embarking on treatment. Often the decision around opting for IVF, to minimise the risk of a multiple pregnancy, or to adopt the cheaper treatment of super ovulation and IUI, but a greater risk of a multiple, revolve around the costs to the patient. This situation is unfortunate as the cost to the health care system and the family, ultimately, are greater when a multiple pregnancy results.
