Unexplained infertility: a review of diagnosis, prognosis, treatment efficacy and management

No evidence for a diminished ovarian reserve among patients with hypertensive disorders of pregnancy: a case control study

BACKGROUND

Existing evidence suggests a relation between cardiovascular dysfunction and diminished ovarian reserve. While it is known that pre-existent cardiovascular dysfunction is also associated with the development of preeclampsia (PE) during pregnancy, we hypothesize that signs of diminished ovarian reserve may occur more frequently among women with a history of hypertensive disorders of pregnancy (HDP). The aim of our study was therefore to analyse if women with a history of HDP show signs of diminished ovarian reserve, represented by lower anti-Mullarian hormone (AMH) levels, compared to controls. For this retrospective observational case control study, patients included women with a history of HDP, whereas controls constituted of women with a history of an uncomplicated pregnancy. The study was conducted in a tertiary referral centre in which all women underwent a one-time cardiovascular and metabolic assessment. Ovarian reserve and markers of cardiovascular function were evaluated, adjusted for age and body mass index (BMI) using linear regression analyses.

RESULTS

163 patients and 81 controls were included over a time span of 3 years. No signs of diminished ovarian reserve i.e. lower AMH level were observed in the patient group versus controls. A subgroup analysis even showed higher AMH levels in late onset HDP as compared to controls (2.8 vs. 2.0 µg/L, p = 0.025). As expected, cardiovascular function markers were significantly less favourable in the patient group compared to controls; higher levels of systolic blood pressure (BP) (5%), diastolic BP (4%), triglycerides (29%), glucose (4%) and insulin levels (81%) (all p < 0.05), whereas high density lipid (HDL) cholesterol was 12% lower (NS).

CONCLUSIONS

Despite unfavourable cardiovascular risk profile, the present study does not substantiate the hypothesis that women with HDP show accelerated ovarian ageing as compared to healthy parous controls. Although HDP patients should be warned about their cardiovascular health, they shouldn't be concerned about unfavourable ovarian reserve status.

New Insights on Sperm Function in Male Infertility of Unknown Origin: A Multimodal Approach

The global trend of rising (male) infertility is concerning, and the unidentifiable causes in half of the cases, the so-called unknown origin male infertility (UOMI), demands a better understanding and assessment of both external/internal factors and mechanisms potentially involved. In this work, it was our aim to obtain new insight on UOMI, specifically on idiopathic (ID) and Unexplained male infertility (UMI), relying on a detailed evaluation of the male gamete, including functional, metabolic and proteomic aspects. For this purpose, 1114 semen samples, from males in couples seeking infertility treatment, were collected at the Reproductive Medicine Unit from the Centro Hospitalar e Universitário de Coimbra (CHUC), from July 2018-July 2022. Based on the couples' clinical data, seminal/hormonal analysis, and strict eligibility criteria, samples were categorized in 3 groups, control (CTRL), ID and UMI. Lifestyle factors and anxiety/depression symptoms were assessed via survey. Sperm samples were evaluated functionally, mitochondrially and using proteomics. The results of Assisted Reproduction Techniques were assessed whenever available. According to our results, ID patients presented the worst sperm functional profile, while UMI patients were similar to controls. The proteomic analysis revealed 145 differentially expressed proteins, 8 of which were specifically altered in ID and UMI samples. Acrosin (ACRO) and sperm acrosome membrane-associated protein 4 (SACA4) were downregulated in ID patients while laminin subunit beta-2 (LAMB2), mannose 6-phosphate isomerase (MPI), ATP-dependent 6-phosphofructokinase liver type (PFKAL), STAR domain-containing protein 10 (STA10), serotransferrin (TRFE) and exportin-2 (XPO2) were downregulated in UMI patients. Using random forest analysis, SACA4 and LAMB2 were identified as the sperm proteins with a higher chance of distinguishing ID and UMI patients, and their function and expression variation were in accordance with the functional results. No alterations were observed in terms of lifestyle and psychological factors among the 3 groups. These findings obtained in an experimental setting based on 3 well-defined groups of subjects, might help to validate new biomarkers for unknown origin male infertility (ID and UMI) that, in the future, can be used to improve diagnostics and treatments.

The Male Is Significantly Implicated as the Cause of Unexplained Infertility

Male infertility is recognized as a relatively common, complex condition, generated by a broad array of environmental and genetic factors. Historical reliance on the conventional semen profile has tended to underestimate the true contribution of "the male factor" to human infertility. This review highlights the importance of genetic and epigenetic factors in the etiology of male infertility, identifying a range of mutations responsible for primary testicular failure and impaired fertilizing potential. More than three quarters of all de novo mutations arise in the male germline via mechanisms that involve the inefficient or defective repair of DNA damage. Understanding the range of factors capable of creating genetic turmoil in the paternal germline is essential, if we are to gain a deep understanding of the causes of male infertility, rather than just the symptoms that characterize its presence. High levels of DNA fragmentation induced by oxidative stress are part of this equation. Oxidative stress is, in turn, driven by biological (age, ejaculation frequency, varicocele, infection), lifestyle (smoking, obesity), and environmental factors (heat, other forms of electromagnetic radiation, and toxins) that can impair the fertilizing potential of the spermatozoa and influence the incidence of spontaneous mutations that may cause infertility in the offspring.

Improving reproductive outcomes of intrauterine insemination: Does endometrial scratch injury help? A randomised controlled trial

OBJECTIVE(S)

Current evidence suggests that endometrial injury improves clinical pregnancy rate while having no effect on miscarriages in women undergoing IVF/ICSI. However, there is no substantial evidence to advocate the use of endometrial injury to benefit the outcomes of IUI treatment. Additionally, there is no clear consensus about the ideal timing, underlying mechanism and optimum intensity of endometrial injury required. The study examines the effect of intentional endometrial injury/scratch in the early proliferative phase of stimulated cycle on reproductive outcomes (clinical and ongoing pregnancy rates and miscarriage occurrence) of intra-uterine insemination treatment (IUI).

STUDY DESIGN, SIZE, DURATION

This prospective, randomized control interventional study was conducted in a tertiary level teaching institution from April 2018 to February 2020. 150 eligible couples requiring IUI treatment who agreed to participate were randomly allocated on 1:1 basis to either control or intervention group. The trial participants received up to 3 cycles ovulation induction with clomiphene citrate and intra-uterine insemination. In addition, women in intervention group were subjected to endometrial scratch injury on day 6-7 of their stimulated cycle. 154 cycles in control arm and 128 cycles in intervention group were analyzed for clinical pregnancy, miscarriages and pain experienced by the women during endometrial scratch injury using the statistical package SPSS (version 21).

RESULT

Similar cumulative clinical pregnancy rates (12.5% Vs 13.6%, RR 1.21, 95% CI 0.44-3.37, p = 0.713), biochemical pregnancy rates (17.1% vs 22.9%, RR 1.43, CI 0.59-3.47, p = 0.421) and ongoing pregnancy rates (10.93% Vs 11.47%, RR 1.05, CI 0.35-3.21, p = 924) were observed in control and intervention arms. Likewise, the relative risk of miscarriage occurrence in the intervention arm was 1.32 (95% CI 0.39-4.32, p = 1.000) which was not statistically different from control group. Mean pain score of 6.93 on numerical pain rating scale was experienced by women whilst having endometrial scratch injury.

CONCLUSIONS

There is insufficient evidence to defend the use of endometrial scratch injury in intra-uterine insemination treatment, as it is moderately painful and have uncertain beneficial influence on reproductive outcomes.

Special characteristics, reproductive, and clinical profile of women with unexplained infertility versus other causes of infertility: a comparative study

PURPOSE

To investigate whether women with unexplained infertility (UI) demonstrate different demographic and IVF characteristics compared to those with other causes of infertility.

METHODS

Data on 245 couples that underwent a total of 413 IVF/ICSI cycles were analyzed (UI 114 cycles, 73 women; anovulation (PCO/PCOS) 83 cycles, 51 women; tubal factor 85 cycles, 47 women; male factor 131 cycles, 74 women). Features of UI were compared versus other infertility groups, after adjustment for multiple comparisons. Generalized least squares (GLS) and random-effects logistic regression analysis were also performed.

RESULTS

Live birth rates, consisting of the primary outcome, were similar in all compared infertility groups. Compared to male infertility, UI was associated with woman's older age at cycle, lower body mass index (BMI), and higher follicle-stimulating hormone (FSH). Compared to tubal infertility, UI was linked to lower endometrial thickness at oocyte retrieval and lower BMI; compared to anovulatory infertility related to PCO/PCOS, UI was linked to woman's older age, more frequent smoking, and poorer ovarian reserve tests (FSH and antral follicle count). After adjustment for other types of infertility, woman's age, age at menarche, and FSH levels, anovulatory infertility presented with higher odds of clinical pregnancy compared to UI (adjusted OR = 2.13, 95% C: 1.01-4.52).

CONCLUSIONS

Infertile women with UI undergoing assisted reproduction demonstrate different demographic and clinical characteristics compared to those of other causes of infertility, albeit live birth rates are similar.

The management of unexplained infertility: an evidence-based guideline from the Canadian Fertility and Andrology Society

Unexplained infertility is a common diagnosis affecting as many as 50% of couples seeking infertility care. As a diagnosis of exclusion, its treatment remains largely empirical. Historically, a step-wise progression in treatment has been initiated with the least invasive, least expensive option followed by a gradual progression to therapies using assisted reproductive technology. In recent years there have been advocates for more rapid-progression IVF. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based recommendations for the treatment of unexplained infertility, including expectant management, laparoscopy, intrauterine insemination (IUI) alone, ovarian stimulation with oral agents or gonadotropins alone, ovarian stimulation + IUI, and IVF. The quality of supporting evidence for each recommendation is evaluated using the framework outlined by the Canadian Task Force on Preventive Health Care. This guideline recognizes that the therapeutic approach should be individualized taking into account patient age and duration of infertility, and emphasizes those strategies that are most likely to result in a healthy live birth.

Effects of clomiphene citrate for prevention of premature luteinizing hormone surge in those undergoing intrauterine insemination outcome: A randomized, double-blind, placebo-controlled trial

The objective of the study is to determine the effects of clomiphene citrate (CC) on preventing premature luteinizing hormone (LH) surge in infertile patients with polycystic ovary syndrome (PCOS) undergoing intrauterine insemination (IUI). This was a randomized clinical trial being performed at Shiraz Mother and Child Hospital. We included 162 women with PCOS selected for IUI cycles. Patients were randomly allocated to receive 150 mg/day CC from the 8^th of the cycle though the day of human chorionic gonadotropin (hCG) injection (n = 81) or nothing in the same period (n = 81). Main outcomes included the incidence of premature LH surge, pregnancy rate, abortion and ongoing pregnancy rates, number of maturing follicles, and endometrial thickness. The incidence of premature LH surge was significantly lower in those who received CC (3.0% vs. 14.9%; P = 0.021). The pregnancy rate was 10 (15.1%) and 6 (8.9%) in CC and control groups, respectively (P = 0.342). The ongoing pregnancy rate found to be comparable between two study groups (12.1% vs. 5.9%; P = 0.068). Serum level of estradiol (E₂) level at the time of hCG administration was significantly higher in those who were treated with CC when compared to control (1153.5 ± 326.4 vs. 943.2 ± 215.3; P < 0.001). Patients who received CC also had higher number of mature follicles >18 mm when compared to controls (3.85 ± 1.3 vs. 2.94 ± 1.01; P < 0.001). Administration of CC from the 8^th day of the cycle to the day of hCG injection in combination with Gonal-f in infertile patients with CC-resistant PCOS undergoing IUI cycles is associated with decreased incidence of premature LH surge, higher E₂levels, and higher number of mature ovarian follicles. This protocol is safe and simple and could be considered to be cost-effective.

Antimüllerian hormone levels and antral follicle counts are not reduced compared with community controls in patients with rigorously defined unexplained infertility

OBJECTIVE

To test the hypothesis that women with unexplained infertility demonstrate evidence of diminished ovarian reserve when compared with a population of community controls.

DESIGN

Cross-sectional study.

SETTING

Multicenter university-based clinical practices.

PATIENT(S)

Study participants included 277 healthy, normo-ovulatory female partners with rigorously defined unexplained infertility randomly selected from a multicenter trial (Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation). Controls included 226 healthy, normo-ovulatory women not seeking treatment for fertility from a community-based cohort (Ovarian Aging study).

INTERVENTION(S)

Serum antimüllerian hormone (AMH) assay at a central laboratory, FSH, fasting serum metabolic testing, transvaginal ultrasonography for antral follicle counts (AFCs), anthropometric measurements.

MAIN OUTCOME MEASURE(S)

Average AMH, AFC, and AMH/AFC were compared between infertile and control women by age. Analyses of covariance compared these outcomes while controlling for confounders, including age, race, body mass index, smoking history, and study site.

RESULT(S)

In our models, AMH, AFC, and AMH/AFC ovarian reserve indices did not differ between infertile women and community-based controls, after controlling for age, race, body mass index, smoking history, and study site.

CONCLUSION(S)

Currently utilized predictors of ovarian reserve do not discriminate women with rigorously defined unexplained infertility from healthy community-based women of similar demographic characteristics. Contrary to our hypothesis, among women with FSH in the normal range (≤12 IU/L), women with unexplained infertility did not show evidence of decreased ovarian reserve as measured by AMH and AFC. Ovarian reserve markers in isolation may not serve as predictors of future fertility.

Risk of infertility following pelvic angiographic embolization in female patients with pelvic fractures: A nationwide population-based cohort study in Taiwan

Pelvic angiographic embolization is an effective procedure to provide haemostasis in patients with pelvic fractures. However, management with repeated follow-up radiographs may result in infertility. The study aimed to evaluate the risk of infertility following pelvic fracture treated with pelvic angiographic embolization in female patients. We used data from the National Health Insurance Research Database (NHIRD) provided by the Bureau of National Health Insurance of the Department of Health in Taiwan from the period of 1997–2010. A total of 36 and 18,029 patients were included in the case and control cohorts, respectively. The risk estimations for the case and control cohorts were compared using a Cox’s proportional hazards regression model. The significance level was set at <0.05. After adjusting for possible confounding factors, the incidence of infertility in the case cohort was nearly 30.7-fold higher than that in the control cohort (adjust hazard ratio [HR] = 30.7, 95% confidence interval [CI] = 10.643–70.109). Patients between 15–35 years of age had a much higher incidence of infertility in the case cohort than in the control cohort (adjusted HR = 49.9, 95% CI = 15.177–64.099). Taken together, pelvic fractures in female patients treated with arterioembolization for haemostasis might be associated with a higher risk of infertility in Taiwan. Physicians should be aware of the link and inform patients of this risk prior to arterioembolization.

The Roles of Anandamide, Fatty Acid Amide Hydrolase, and Leukemia Inhibitory Factor on the Endometrium during the Implantation Window

BACKGROUND/AIMS

We investigated the role of the endocannabinoid system (ECS) in the endometrium of unexplained infertility (UI) patients, and effect of anandamide (AEA) on leukemia inhibitory factor (LIF).

METHODS

Patients were divided into UI and control groups. Endometrium samples were collected at the midluteal phase. Levels of cannabinoid type 1 (CB1), fatty acid amide hydrolase (FAAH), and LIF were examined. LIF productions were measured after AEA, CB1 antagonist AM251, and CB2 antagonist AM630 stimulation.

RESULTS

Rates of available embryo, successful implantation and pregnancy, and the endometrial thickness of UI group were significantly lower than control, suggesting uterine receptivity was decreased in UI group. FAAH and LIF levels were significantly decreased, whereas endometrial CB1 was slightly increased in UI group. LIF production was promoted by low amount of AEA administration (1-10 μM), while the promotion was reduced by higher concentration of AEA (50 μM). LIF levels were decreased by AM251 or AM630, compared with AEA alone. Expressions of FAAH and LIF were closely associated with uterus receptivity and implantation rate of UI patients. Different concentrations of AEA could stimulate dynamic changes in LIF production.

CONCLUSION

Our data indicated the important role of the ECS in human fertility, which may promote new strategies for successful implantation and treatments for reproductive diseases.

Testicular versus ejaculated spermatozoa in ICSI cycles of normozoospermic men with high sperm DNA fragmentation and previous ART failures

As a part of male assessment, conventional sperm parameters including morphologic features have been dedicated as major factors influencing fertilisation and pregnancy rates in assisted reproductive technology (ART). Genomic integrity of spermatozoa has also been found to influence fertility prognosis, and hence, sperm DNA fragmentation index (DFI) has been adopted by many centres to document this entity. Despite several suggested approaches, there is lack of universal consensus on optimising fertility outcomes in males with high sperm DFI. In this context, the results from cycles using testicular spermatozoa (TESA) obtained by aspiration were compared with those of ejaculated spermatozoa (EJ) in normozoospermic subjects with high sperm DFI and previous ART failures. Clinical (41.9% versus 20%) and ongoing pregnancy rates (38.7% versus 15%) were significantly better and miscarriages were lower in TESA group when compared to EJ group. Sperm DFI should be a part of male partner's evaluation following unsuccessful ART attempts. When high DFI is detected (>30%), ICSI using testicular spermatozoa obtained by TESA seems an effective option particularly for those with repeated ART failures in terms of clinical, ongoing pregnancies and miscarriages even though conventional sperm parameters are within normal range.

Predictors of pregnancy and live-birth in couples with unexplained infertility after ovarian stimulation-intrauterine insemination

OBJECTIVE

To identify baseline characteristics of couples that are likely to predict conception, clinical pregnancy, and live birth after up to four cycles of ovarian stimulation with IUI in couples with unexplained infertility.

DESIGN

Secondary analyses of data from a prospective, randomized, multicenter clinical trial investigating pregnancy, live birth, and multiple pregnancy rates after ovarian stimulation-IUI with clomiphene citrate, letrozole, or gonadotropins.

SETTING

Outpatient clinical units.

PATIENT(S)

Nine-hundred couples with unexplained infertility who participated in the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation clinical trial.

INTERVENTION(S)

As part of the clinical trial, treatment was randomized equally to one of three arms and continued for up to four cycles or until pregnancy was achieved.

MAIN OUTCOME MEASURE(S)

Conception, clinical pregnancy, and live-birth rates.

RESULT(S)

In a multivariable logistic regression analysis, after adjustment for other covariates, age, waist circumference, income level, duration of infertility, and a history of prior pregnancy loss were significantly associated with at least one pregnancy outcome. Other baseline demographic and lifestyle characteristics including smoking, alcohol use, and serum levels of antimüllerian hormone were not significantly associated with pregnancy outcomes.

CONCLUSION(S)

While age and duration of infertility were significant predictors of all pregnancy outcomes, many other baseline characteristics were not. The identification of level of income as a significant predictor of outcomes independent of race and education may reflect differences in the underlying etiologies of unexplained infertility or could reveal disparities in access to fertility and/or obstetrical care.

CLINICAL TRIAL REGISTRATION

NCT01044862.

Screening for Chlamydia trachomatis in Egyptian women with unexplained infertility, comparing real-time PCR techniques to standard serology tests: case control study

BACKGROUND

To study the prevalence of Chlamydia infection in women with primary and secondary unexplained infertility using ELISA technique for antibody detection and real time, fully automated PCR for antigen detection and to explore its association with circulating antisperm antibodies (ASA).

METHODS

A total of 50 women with unexplained infertility enrolled in this case control study and a control group of 44 infertile women with a known cause of infertility. Endocervical specimens were collected for Chlamydia antigen detection using PCR and serum samples for antibodies detection. Circulating anti-sperm antibodies were detected using sperm antibody Latex Agglutination tests.

RESULTS

The overall prevalence of Chlamydial infection in unexplained infertility cases as detected by both ELISA and PCR was 40 % (20/50). The prevalence of current Chlamydial genital infection as detected by real-time PCR was only 6.0 % (3/50); two of which were also IgM positive. Prevalence of ASA was 6.0 % (3/50); all were sero-negative for anti-C.trachomatis IgM and were PCR negative.

CONCLUSION

The incidence of Chlamydial infection in Egyptian patients with unexplained infertility is relatively high. In the setting of fertility investigations; screening for anti. C.trachomatis antibodies using ELISA, and treatment of positive cases should be considered. The presence of circulating ASA does not correlate with the presence of old or current Chlamydia infection in women with unexplained infertility.

Unexplained male infertility: diagnosis and management

Unexplained male infertility is a diagnosis reserved for men in whom routine semen analyses results are within normal values and physical as well as endocrine abnormalities were ruled out. In addition to erectile problems and coital factors, immunologic causes and sperm dysfunction may contribute to such condition. New etiologies of unexplained male infertility include low level leukocytospermia and mitochondrial DNA polymerase gene polymorphism. Contemporary andrology may reveal cellular and sub-cellular sperm dysfunctions which may explain subfertility in such cases, thus aiding the clinician to direct the further work-up, diagnosis and counseling of the infertile male. The objective of this article is to highlight the concept of unexplained male infertility and focuses on the diagnosis and treatment of this condition in the era of modern andrology and assisted reproductive techniques. Extensive literature review was performed using the search engines: Pubmed, Science-direct, Ovid and Scopus.

Evaluation of FAS and caspase-3 in the endometrial tissue of patients with idiopathic infertility and recurrent pregnancy loss

OBJECTIVE

To investigate expression of BcL-2, FAS, FAS ligand (FASL) and cleaved caspase-3 in the endometrial tissue of women with idiopathic infertility (with two consecutive failed cycles of in vitro fertilization) and women with idiopathic recurrent pregnancy loss. The control group consisted of fertile women.

STUDY DESIGN

Endometrial tissue samples from fertile women (n=25), women with idiopathic infertility (n=25) and women with idiopathic recurrent pregnancy loss (n=25) were collected on the seventh or eighth postovulatory day of their menstrual cycles for evaluation. Expression of BcL-2, FAS, FASL and cleaved caspase-3 was assessed using immunohistochemical methods.

RESULTS

Expression of BcL-2 and FAS was significantly higher and lower, respectively, in the women with idiopathic infertility than in the other groups (p<0.01). Expression of cleaved caspase-3 was significantly lower in the women with idiopathic infertility than in the other groups (p<0.01). Expression of FASL was similar in all three groups.

CONCLUSION

Disturbances in endometrial apoptosis may be a contributing factor in patients with idiopathic infertility and recurrent pregnancy loss.

Extended letrozole regimen versus clomiphene citrate for superovulation in patients with unexplained infertility undergoing intrauterine insemination: a randomized controlled trial

BACKGROUND

The aim of this randomized controlled trial was to compare the efficacy of extended letrozole regimen with clomiphene citrate in women with unexplained infertility undergoing superovulation and intrauterine insemination (IUI).

METHODS

Two hundred and fourteen patients with unexplained infertility were randomized into two equal groups using computer generated list and were treated by either letrozole 2.5 mg/day from cycle day 1 to 9 (extended letrozole group, 211 cycles) or clomiphene citrate 100 mg/day from cycle day 3 to 7 (clomiphene citrate group,210 cycles). Intrauterine insemination was performed 36 to 40 hours after HCG administration.

RESULTS

Both groups were comparable with regard to number of mature follicles (2.24 +/- 0.80 Vs 2.13 +/- 0.76) and the day of HCG administration. Serum estradiol was significantly greater in clomiphene citrate group (356 +/- 151 Vs 822 +/- 302 pg/ml, P = < 0.001) and the endometrial thickness was significantly greater in extended letrozole group (9.10 +/- 1.84 Vs 8.18 +/- 1.93 mm, P = < 0.001).The pregnancy rate per cycle and cumulative pregnancy rate were significantly greater in extended letrozole group (18.96% Vs 11.43% and 37.73% Vs 22.86%, respectively).

CONCLUSION

The extended letrozole regimen had a superior efficacy as compared with clomiphene citrate in patients of unexplained infertility undergoing superovulation and IUI.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01232075.

Effects of physiotherapeutic TENS in a woman with unexplained infertility

Unexplained infertility (UI) is a difficult diagnosis in the field of obstetrics and gynaecology. This report describes TENS treatment as an adjunct therapy for a 30-year-old woman with long-standing UI who was scheduled to undergo ovarian stimulation for in vitro fertilization (IVF) and embryo transfer. She had three unsuccessful intrauterine insemination treatments. Her last IVF treatment also failed. The treatment consisted of burst-TENS for seven sessions, which was applied daily from the second day of induction of ovulation (IO) to hCG administration. The transvaginal ultrasonography with pulsed Doppler curves was performed to measure the uterine artery impedance indices of Pulsatility Index (PI) and Resistance Index (RI). Before TENS application, on the first day of IO, the PI and RI for right side uterine artery were 3.96 and 0.96, respectively. For left uterine artery, the PI and RI were 6.92 and 1, respectively. After treatment with TENS, on the day of hCG administration, the PI and RI for right side uterine artery were 3.39 and 0.90, respectively. On the left side, they were PI=2.62 and RI=0.86. IVF was performed and on the day of oocytes collection, 22 oocytes were collected and inseminated. Fertilization was confirmed 16 hours after insemination by visualization of 2 pronuclei. A singleton pregnancy was achieved by the presence of a fetal sac during an ultrasound examination. It is concluded that the addition of TENS resulted in remarkable reduction of uterine artery PI and RI and a successful pregnancy after IVF for this woman with UI.

Cumulative clinical pregnancy rates after COH and IUI in subfertile couples

To evaluate the influence of female age and cause of infertility on the outcome of controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI), we studied 2717 COH cycles in 1035 subfertile couples. The cumulative clinical pregnancy rates were 39% and 58% after three and six COH cycles, respectively. The cumulative pregnancy rate significantly decreased with maternal age and differed by cause of infertility. The cumulative pregnancy rate continued to increase with an increase in COH cycle number up to the third, or forth cycle, in patients with mechanical and combined infertility, respectively, and in up to the second cycle in patients aged 40 years or more. These findings provide treatment guidelines for clinicians in determining the likelihood of treatment success and the point at which to proceed to the next treatment strategy.

Antral follicle count as a predictor of hyperresponse in controlled ovarian hyperstimulation/intrauterine insemination in unexplained sterility

In this prospective study of women with unexplained infertility undergoing the first cycle of controlled ovarian hyperstimulation/intrauterine insemination, the presence of 16 or more antral follicles on day 3 of the cycle was a good predictor of cancellation due to hyperresponse.

Implementation of the NICE guideline – Recommendations from the British Fertility Society for national criteria for NHS funding of assisted conception

Assisted conception providers in England were surveyed to establish the uptake of NICE guideline for infertility particularly in respect of assisted conception and the criteria used to accept patients for NHS funded treatment. Detailed information on selection criteria was obtained from a group of commissioning consortia at an advanced stage in their arrangements. While there was an overall increase in the number of NHS IVF cycles purchased in England, implementation is stalled at one fresh cycle in the vast majority of Primary Care Trusts (PCTs). There is little consensus about the criteria used for acceptance into an NHS programme. This is particularly so in respect of social criteria which are often arbitrary and used as a rationing tool. This information complements that provided by the survey of Primary Care Trusts performed in March 2005 by the All Party Parliamentary Group on Infertility (APPGI) in partnership with the National Infertility Awareness Campaign (NIAC) which together provide a basis for recommendations for NHS funding. The recommendations presented should be applied across England and Wales to ensure consistency, fairness and equity of access.

Programming of GnRH feedback controls timing puberty and adult reproductive activity

The timing of puberty generally differs between sexes, and this may be due to sex differences in the organization of steroid feedback systems. We propose that the reproductive neuroendocrine default sex is female. If the individual is male, the feedback control of GnRH secretion is programmed early in development, and the pubertal GnRH rise is either advanced or delayed depending upon species. This developmental programming is by androgens. Early programming also reorganizes adult reproductive neuroendocrine function to change a pattern of cyclic gamete release (periodic ovulations) requiring multiple feedback systems to that of a continuous one (spermatogenesis) requiring only the negative feedback control. The multiple feedback systems underlying the complex ovulatory cycle are innate, and in the male the unnecessary feedbacks are abolished or rendered less sensitive during development by the estrogenic, as well as the androgenic metabolites of testosterone.

Successful pregnancy following transfer of embryos from oocytes with abnormal zona pellucida and cytoplasm morphology

The failed or impaired fertilization in an IVF cycle may be a result of undetected abnormalities in sperm function, poor oocyte quality, or impaired spermatozoon-oocyte interaction. Whether oocyte dysmorphisms have an impact on intracytoplasmic sperm injection (ICSI) outcome, fertilization, and implantation is controversial. A 33-year-old nulligravida female with a 2-year history of primary infertility was referred to the Toronto Centre for Advanced Reproductive Technology for infertility management. The patient underwent several cycles of ovulation induction followed by timed intercourse or intrauterine insemination without a resulting pregnancy. Following the failed insemination cycles, she proceeded to IVF. Six morphologically abnormal oocytes (including three that were cucumber-shaped) were retrieved and all injected with a single spermatozoon. Four oocytes showed normal fertilization and developed to day-3 embryos with abnormal morphology and were transferred. Two weeks after the embryo transfer, the patient had a positive beta-human chorionic gonadotrophin (beta-HCG). The pregnancy was uneventful, and a healthy baby boy was delivered at 41 weeks of age by Caesarean section. Since fertilization, embryo development, and successful pregnancy was achieved in this case, it is recommend that oocytes with extreme morphological abnormalities should not be discarded as ICSI may overcome the barriers to fertilization and cleavage.

Intracytoplasmic sperm injection and conventional in vitro fertilization are complementary techniques in management of unexplained infertility

PURPOSE

To evaluate the role of ICSI in unexplained infertility.

METHODS

In 125 cycles with six or more oocytes retrieved per cycle, sibling oocytes were randomly allocated to IVF or ICSI (group A). In 74 cycles with less than six oocytes retrieved per cycle, cycles were allocated to IVF or ICSI (group B).

RESULTS

In group A, ICSI fertilization rate of 61% per allocated oocyte was higher than IVF fertilization rate of 51.6% (P < 0.001). Complete fertilization failure occurred in 19.2 and 0.8% of cycles in IVF and ICSI, respectively (P < 0.001). In group B, fertilization rate in IVF cycles was 53.3% as compared to 60.7% per allocated oocyte in the ICSI cycles (P = 0.29). Complete fertilization failure was higher (P = 0.02) in conventional IVF (34.3%) than ICSI cycles (10.3%).

CONCLUSIONS

Allocation of sibling oocytes to IVF and ICSI in the first cycle minimizes risk of fertilization failure. For patients with limited number of oocytes, ICSI technique is recommended.

Psychogenic infertility--myths and facts

PURPOSE

The hypothesis of this review is that the role of psychological factors as the sole cause of infertility is generally overrated.

METHODS

A review is given of studies concerning the influence of psychological factors on the development of infertility.

RESULT

A prevalence of psychogenic infertility of 10-15 per cent must be discussed critically. A value of approximately 5 per cent is more realistic. Equating unexplained infertility with psychogenic infertility is not justified. A definition of psychogenic infertility according to the German guidelines Psychosomatics in Reproductive Medicine is presented. Spontaneous pregnancies following adoption or the decision to remain childless are the absolute exception. The association of stress and infertility in humans is still unclear. For many women the effect of infertility and notably of medical therapy is a considerable emotional stress. This may make psychosocial counseling necessary in certain cases.

CONCLUSIONS

An exclusive psychological/psychodynamical point of view on the complexity of infertility is as inadequate as a strictly somatic point of view. Infertility should always be treated as a psychosomatic entirety.

Elevated early follicular gonadotropin levels in women with unexplained infertility do not provide evidence for disordered gonadotropin-releasing hormone secretion as assessed by luteinizing hormone pulse characteristics

OBJECTIVE

To determine whether women with rigorously defined unexplained infertility demonstrated altered GnRH secretion, as reflected by serum LH secretion patterns.

DESIGN

Prospective observational study.

SETTING

National Center for Infertility Research at Michigan.

PATIENT(S)

Nine women with rigorously defined unexplained infertility and 11 healthy, parous age-matched control women.Gonadotropin-releasing hormone (25 ng/kg) as a bolus injection.

MAIN OUTCOME MEASURE(S)

Daytime pulse patterns of LH secretion measured every 10 minutes; mean serum concentrations of LH, FSH, E(2), P, PRL, and cortisol; and response to a physiologic dose of GnRH in the early follicular, late follicular, mid-luteal, and late luteal phases of the same menstrual cycle.

RESULT(S)

Serum LH pulse frequency and pulse amplitude and LH secretion in response to a physiologic bolus of GnRH were not significantly different in unexplained infertility patients at any phase of the cycle. Luteinizing hormone pulse frequency and amplitude, as well as response to GnRH, varied significantly across the cycle. Mean early follicular serum LH and FSH concentrations were significantly higher in unexplained infertility patients than in fertile control subjects (LH: 5.31 +/-.51 vs. 4.03 +/-.33 [mIU/mL +/- SEM]; FSH: 5.81 +/-.63 vs. 3.80 +/-.45) but were not different at any other phase of the cycle.

CONCLUSION(S)

These data do not support the hypothesis that unexplained infertility is caused by an abnormality in pulsatile GnRH secretion or abnormal pituitary sensitivity to GnRH. However, the results are consistent with a difference in negative feedback from the ovary to the pituitary in unexplained infertility patients that is suggestive of diminished ovarian reserve.

Controlled ovarian hyperstimulation and intrauterine insemination for treatment of unexplained infertility should be limited to a maximum of three trials

OBJECTIVE

To investigate the optimum number of cycles of controlled ovarian hyperstimulation and intrauterine insemination in the treatment of unexplained infertility.

DESIGN

Observational prospective study.

SETTING

In vitro fertilization embryo transfer center.

PATIENT(S)

Five hundred ninety-four couples with unexplained infertility.

INTERVENTION(S)

Controlled ovarian hyperstimulation (COH), intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Cycle fecundity.

RESULT(S)

One to 3 cycles of COH/IUI were performed in 594 patients (group A) undergoing 1,112 cycles (mean, 1.9 cycles/patient). Up to 3 further trials (cycles 4-6) of COH/IUI were then performed in 91 of these women (group B), a total of 161 cycles (mean, 1.8 cycles/patient). A historical comparison group C consisted of 131 patients with 3 failed cycles of COH/IUI who underwent 1 cycle of IVF and ICSI at our center. In group A, 182 pregnancies occurred, with a cycle fecundity of 16.4% and a cumulative pregnancy rate (PR) of 39.2% after the first 3 cycles. In group B, 9 pregnancies occurred in cycles 4-6, with a cycle fecundity of 5.6%, significantly lower than that of group A (P<.001). The cumulative PR rose to 48.5% by cycle 6, a further increase of only 9.3%. In the women undergoing IVF and ICSI in group C, 48 pregnancies occurred, with a cycle fecundity of 36.6% per cycle, significantly higher than that of group B (P<.001).

CONCLUSION(S)

In unexplained infertility, the cycle fecundity in the first three trials of COH and IUI was higher than in cycles 4-6, with a statistically significant difference. Patients should be offered IVF or ICSI if they fail to conceive after three trials of COH and IUI.

In vitro fertilization and intracytoplasmic sperm injection for couples with unexplained infertility after failed direct intraperitoneal insemination

PURPOSE

The objective was to determine the optimal insemination technique in patients undergoing in vitro fertilization (IVF) after failed direct intraperitoneal insemination (DIPI) and the outcome of intracytoplasmic sperm injection (ICSI) in such cases.

METHODS

In case-control studies, 53 couples with unexplained infertility who underwent IVF after four failed DIPI cycles were compared with 75 couples with tubal or endometriosis infertility as controls. Thirty couples with unexplained infertility after failing to conceive with DIPI and conventional IVF who underwent ICSI and 58 couples with male-factor infertility as controls also were compared. Fertilization cleavage, embryo quality, implantation, and pregnancy were compared after IVF and after ICSI.

RESULTS

There was a significant difference in fertilization rates after IVF between cases of unexplained infertility after failing to conceive with DIPI (40.4%) and patients with tubal or endometriosis infertility (67.9%). There also was a significant difference in total fertilization failure rates between the two groups (30.4% and 3.9%, respectively). There was a slight but significant difference in numbers of fertilized oocytes after ICSI between patients with low fertilization rate undergoing IVF after failing to conceive DIPI (85.8%) and patients with male factor (90.4%). Total fertilization failure was not observed in these cases.

CONCLUSIONS

Couples with unexplained infertility after failing to conceive with DIPI show a failed fertilization or a low fertilization rate after IVF. However, they demonstrated a good chance of becoming pregnant after subsequent ICSI, even with statistically significant difference in fertilization rate as compared with male-factor cases.

Management of long-standing unexplained infertility: A prospective study

OBJECTIVE

Our purpose was to evaluate a protocol for the management of long-standing unexplained infertility.

STUDY DESIGN

A prospective study was conducted at an in vitro fertilization-embryo transfer center with 485 patients with the diagnosis of long-standing unexplained infertility. Patients were treated by means of controlled ovarian hyperstimulation and intrauterine insemination for a maximum of 3 cycles. Those who did not become pregnant underwent in vitro fertilization and intracytoplasmic sperm injection on sibling oocytes.

RESULTS

Among 485 patients, 921 cycles of controlled ovarian hyperstimulation and intrauterine insemination were performed. The pregnancy rate was 15.7% per cycle and 29.8% per patient. Among those who did not become pregnant, 131 patients underwent in vitro fertilization and intracytoplasmic sperm injection into sibling oocytes; 48 women became pregnant (36.7%). There was total failure of the in vitro fertilization oocytes in 23 cycles (17.6%).

CONCLUSION

Management of long-standing unexplained infertility with controlled ovarian hyperstimulation and intrauterine insemination resulted in a reasonable pregnancy rate. Treatment by means of in vitro fertilization and intracytoplasmic sperm injection into sibling oocytes among patients who did not become pregnant resulted in a good pregnancy rate. The overall results showed that the proposed protocol for management of unexplained infertility is satisfactory.

Comparison of intrauterine insemination with timed intercourse in superovulated cycles with gonadotropins: a meta-analysis

OBJECTIVE

To compare timed intercourse and IUI with the husband's sperm in patients with unexplained infertility who are undergoing superovulation with gonadotropins.

DESIGN

Meta-analysis. All published reports of randomized, prospective studies with an English-language abstract extracted from MEDLINE were analyzed. A crossover search was done from the papers obtained.

SETTING

Academic center.

PATIENT(S)

Couples with unexplained infertility.

INTERVENTION(S)

Meta-analysis of studies evaluating patients superovulated with gonadotropins and randomized for timed intercourse or IUI.

MAIN OUTCOME MEASURE(S)

Pregnancy rates (PRs) were obtained. The common odds ratio (OR) and 95% confidence intervals (95% CI) were calculated.

RESULT(S)

There were 49 pregnancies in 431 cycles of timed intercourse (11.37%), whereas there were 110 pregnancies in 549 cycles of IUI (20.04%). The PRs for IUI were significantly increased compared with those for timed intercourse in superovulation cycles (common OR = 1.84; 95% CI = 1.30-2.62).

CONCLUSION(S)

On the basis of the meta-analysis of 980 cycles in randomized and prospective studies, a patient's chances of becoming pregnant are greater with IUI with her husband's sperm than with timed intercourse in cycles superovulated with gonadotropins.

Intensive hormone monitoring in women with unexplained infertility: evidence for subtle abnormalities suggestive of diminished ovarian reserve

OBJECTIVE

To determine hormone levels across the menstrual cycle in women with rigorously defined unexplained infertility.

DESIGN

Prospective study.

SETTING

National Center for Infertility Research at Michigan.

PATIENT(S)

Evaluation of 1,885 women with infertility identified 12 women who met the following rigorously defined criteria for unexplained infertility: [1] infertility of > or = 24 months' duration, with no male factor, anatomic or functional disorders of the reproductive tract, or immunologic infertility; [2] normal body mass index (BMI); (3) ovulatory cycles ranging from 26 to 32 days; [4] normal luteal phase determined by endometrial biopsy; and [5] normal baseline hormonal profile. Controls (n = 12) were healthy, parous women with normal ovulatory cycles and normal hormonal screens, and were matched for age and BMI with patients.

MAIN OUTCOME MEASURE(S)

Daily gonadotropin and steroid hormone levels across the menstrual cycle.

RESULT(S)

Basal FSH and LH levels in the early, middle and late follicular phases were increased significantly in the group with unexplained fertility compared with the normal controls. The mean (+/-SD) early follicular FSH levels were 7.0 +/- 0.57 mIU/mL in the unexplained-infertility group and 4.7 +/- 0.37 mIU/mL (conversion factor to SI units, 1.00) in the normal controls, respectively. There was no difference between groups over the periovulatory or luteal phase. Midluteal mean (+/-SD) P levels were lower in the unexplained-infertility group than in the normal controls (13.7 +/- 1.6 versus 24.0 +/- 3.2 ng/mL [conversion factor to SI units, 3.180]). Mean E2 concentrations were elevated in the group with unexplained infertility versus normal controls in the early through the late follicular phase but reached significance only in the midfollicular phase. Mean prolactin levels were elevated consistently across the menstrual cycle in the unexplained-infertility group compared with those in normal controls but reached significance only in the early and late follicular and midluteal phases of the cycle. Cortisol concentrations were similar between the two groups.

CONCLUSION(S)

These data indicate that there are subtle alterations in various hormones measured across the menstrual cycle in women with unexplained infertility compared with those in normal controls, suggesting a diminished ovarian reserve.

Unexplained infertility: evaluation of the luteal phase; results of the National Center for Infertility Research at Michigan

OBJECTIVE

To evaluate the luteal phase in women with rigorously defined unexplained infertility.

DESIGN

Prospective study.

SETTING

National Center for Infertility Research at Michigan.

PATIENT(S)

Evaluation of 1,885 women with infertility identified 12 women who met the rigorously defined criteria for unexplained infertility: [1] infertility of > or = 24 months duration, with no male factor, anatomic-functional disorders of the reproductive tract, or immunologic infertility; [2] normal body mass index (BMI); [3] ovulatory cycles ranging from 26 to 32 days; [4] normal luteal phase determined by endometrial biopsy; and [5] normal baseline hormonal profile. Controls (n = 12) were healthy, parous women with normal ovulatory cycles, normal hormonal screen, and were matched for age and BMI to patients.

MAIN OUTCOME MEASURE(S)

Pattern of follicular growth rate and luteal phase hormonal profile.

RESULT(S)

Women with unexplained infertility did not differ in menstrual cycle characteristics, follicular growth rate or mean preovulatory follicle diameter, or endometrial biopsy dating. The mean levels of P tended to be lower in the unexplained infertility group throughout the luteal phase, but only the midluteal interval reached statistical significance. Luteal phase mean integrated P or urinary PDG levels of unexplained infertility women did not differ from those of fertile controls. The ratio of integrated E2:P also was significantly greater in women with unexplained infertility than in fertile controls.

CONCLUSION(S)

Women with rigorously defined unexplained infertility have subtle hormonal anomalies during the luteal phase when compared with fertile controls.

Some cases of human male infertility are explained by abnormal in vitro human sperm activation

OBJECTIVE

To determine if a human sperm activation assay can be used to evaluate males exhibiting otherwise unexplained infertility.

DESIGN

Sperm from age-matched fertile and idiopathic infertile males were assayed in the human sperm activation assay and the results were compared. A portion of the sperm from the idiopathic infertile males also was used in assisted reproductive technology (ART) attempts at pregnancy.

PATIENTS

Idiopathic infertile couples who had extensive fertility testing with no identified problems that would explain their infertility. Fertile males that had fathered one or more children.

MAIN OUTCOME MEASURES

Sperm nuclear decondensation-recondensation and DNA synthesis. Pregnancies resulting from ART using semen from a male whose sperm responded abnormally in the human sperm activation assay.

RESULTS

Thirteen (22%) of 59 idiopathic infertile males produced sperm that responded abnormally in the human sperm activation assay. Only 1 (1.7%) of 59 fertile males produced sperm that responded abnormally in the human sperm activation assay. The percentage of abnormal responders in the patient group exhibiting unexplained infertility was significantly higher than in the fertile male group. No sperm samples that responded abnormally in the human sperm activation assay resulted in pregnancies when used in ART.

CONCLUSIONS

The human sperm activation assay is a new and independent indicator for some cases of infertility that otherwise would be unexplained. The human sperm activation assay appears to have utility in determining a sperm sample's efficacy for fertilization in ART attempts at pregnancy.