Introduction <p>Hysteroscopy remains the gold standard for diagnosis and treatment of intrauterine pathologies, though its invasive nature, cost, and potential complications warrant careful consideration.Discussions about hysteroscopy before embryo transfer are abundant, while there is limited research available on the effect of hysteroscopy before Intrauterine insemination (IUI), especially Intrauterine insemination with donor sperm (IUI-D), and the existing evidence about its necessityin IUI cycles remains controversial.</p> Materials and methods <p>Propensity score matching (PSM) was used to adjust the baseline features at a ratio of 1:3. After PSM, there were 369 patients in the hysteroscopy group and 956 patients in the control group. We statistically analyzed all intrauterine abnormalities encountered during diagnostic hysteroscopy prior to IUI-D and compared the pregnancy outcomes between patients who underwent diagnostic hysteroscopy and those who did not. Simultaneously, pregnancy outcomes were compared between individuals with normal and abnormal hysteroscopic findings within the hysteroscopy group through logistic regression analysis. The primary outcome was live birth following the first IUI-D cycle.</p> Results <p>The live birth rate was 17.89% (66 of 369) in the hysteroscopy group compared with 20.92% (200 of 956) in the control group (<i>P</i> = 0.216). Within the hysteroscopy group, pregnancy outcomes were similar between women with normal and abnormal findings in subgroup analysis.</p> Conclusions <p>The decision to perform diagnostic hysteroscopy prior to IUI-D should be individualized, balancing potential benefits against the risks of complications and treatment delay.</p>