A simple method for fallopian tube sperm perfusion using a blocking device in the treatment of unexplained infertility

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

A Randomised Comparative Study of Standard IUI (sIUI) and Fallopian Tube Sperm Perfusion (FSP) for Clinical Pregnancy

Objectives

To compare the pregnancy rates of two methods of intrauterine insemination (IUI), i.e. standard IUI (sIUI) and fallopian tube sperm perfusion (FSP).

Methods

This prospective randomised parallel study design included 160 infertile women < 38 years of age where IUI was indicated. We recorded a detailed history and conducted a careful clinical examination with the performance of baseline investigations. Each patient was randomly allocated into two groups: Group sIUI (n = 80) and Group FSP (n = 80). The patients underwent two cycles of IUI for achieving clinical pregnancy. The conception of pregnancy among both groups was noted and compared.

Results

The mean age of the females, mean age of the male partners, and duration of marriage in Group sIUI and FSP were comparable (p > 0.05). Compared to the sIUI group, the FSP group had significantly higher patients who conceived (15.97% vs. 6.54%, P = 0.016). In the cases with unexplained infertility, in cycle 2, in the FSP group, there were significantly more patients who conceived (21.05% vs. 0.00%, P = 0.047).

Conclusion

We conclude that FSP over two treatment cycles offers an advantage over the standard IUI and could replace the sIUI in specific indications such as unexplained infertility for artificial insemination. It could be used as an alternative for couples with non-tubal infertility before moving on to IVF treatment.

The comparison between Intrauterine Insemination and Fallopian Tube Sperm Perfusion Using FAST®System in Patients with Unexplained Infertility

Background

Controlled ovarian stimulation (COH) with intrauterine insemination (IUI) is commonly offered to infertile couples with patent fallopian tubes because it is simple, non-invasive and cost-effective technique. Another non-invasive method is fallopian tube sperm perfusion (FSP). This study was performed to compare the relative efficacy between FSP using fallopian sperm transfer (FAST) system and standard IUI in patients with unexplained infertility.

Materials and Methods

This prospective randomized study was conducted at the IVF Unit, Department of Gynecology and Obstetrics, Mazandaran University of Medical Sciences, Sari, Iran, from March 2011 to February 2012. A total of ninety patients with unexplained infertility underwent ovarian stimulation with clomiphene citrate and human menopausal gonadotropin (HMG). Patients were then randomly assigned into either group I (n=45) to undergo standard IUI or group II (n=45) to undergo FSP using FAST system.

Results

The patients’ basic characteristics, including age, primary infertility and duration of infertility, were not significantly different between two study groups. In the group I, there were 9 pregnancies (a pregnancy rate per cycle of 20%), whereas in the group II, 8 pregnancies occurred (a pregnancy rate per cycle of 17.8%, p>0.05).

Conclusion

FSP using FAST system offers no advantage over the standard IUI in order to increase pregnancy rate in patients with unexplained infertility.

Intrauterine insemination versus fallopian tube sperm perfusion for non-tubal infertility

BACKGROUND

Intrauterine insemination (IUI) is a common treatment for couples with subfertility that does not involve the fallopian tubes. It is used to bring the sperm close to the released oocyte. Another method of introducing sperm is fallopian tube sperm perfusion (FSP). Fallopian tube sperm perfusion ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. These treatments are often used in combination with ovarian hyperstimulation.

OBJECTIVES

To compare intrauterine insemination versus fallopian tube sperm perfusion in the treatment of non-tubal subfertility, for live birth and pregnancy outcomes.

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group Trials Register, MEDLINE, CINAHL and EMBASE from inception to September 2013. We also searched study reference lists and trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing IUI with FSP in couples with non-tubal subfertility were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed study quality and extracted the data. If studies were sufficiently similar, data were combined using a fixed-effect model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). A random-effects model was used if substantial statistical heterogeneity was detected. Studies that included participants with unexplained or mixed (non-tubal) subfertility were analysed separately from studies restricted to participants with mild or moderate male factor subfertility. The overall quality of evidence for the main outcomes was summarised using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

MAIN RESULTS

The review included 16 RCTs. Fourteen RCTs (1745 women) were included in the meta-analysis. Only three studies reported live birth per couple. No evidence of a statistically significant difference was noted between IUI and FSP in live birth (OR 0.94, 95% CI 0.59 to 1.49, three RCTs, 633 women, I(2) = 0%, low-quality evidence) or clinical pregnancy (OR 0.75, 95% CI 0.49 to 1.12, 14 RCTs, 1745 women, I(2) = 52%, low-quality evidence). These findings suggest that for a couple with a 13% chance of live birth using FSP, the chance when using IUI will be between 8% and 19%; and that for a couple with a 19% chance of pregnancy using FSP, the chance of pregnancy when using IUI will be between 10% and 20%. Nor was evidence found of a statistically significant difference between IUI and FSP in per-pregnancy of multiple pregnancy (OR 0.96, 95% CI 0.44 to 2.07, eight RCTs, 197 women, I(2) = 0%, low-quality evidence), miscarriage (OR 1.23, 95% CI 0.60 to 2.53, seven RCTs, 199 women, I(2) = 0%, low-quality evidence) or ectopic pregnancy (OR 1.71, 95% CI 0.42 to 6.88, four RCTs, 111 women, I(2) = 0%, very low quality evidence). Substantial heterogeneity was noted for the outcome of clinical pregnancy (I(2) = 54%), for which no clear explanation was provided.

AUTHORS' CONCLUSIONS

Currently no clear evidence suggests any difference between IUI and FSP with respect to their effectiveness and safety for treating couples with non-tubal subfertility. However, a high level of uncertainty is evident in the findings, and additional research may be useful.

Intrauterine insemination versus fallopian tube sperm perfusion in non-tubal infertility

BACKGROUND

Controlled ovarian hyperstimulation (COH) combined with intrauterine insemination (IUI), using a volume of 0.5 ml of inseminate is commonly offered to couples with non-tubal sub fertility. Another method is Fallopian tube sperm perfusion (FSP) which is based on a pressure injection of 4 ml of sperm suspension while attempting to seal the cervix to prevent semen reflux. This technique ensures the presence of higher sperm density in the fallopian tubes at the time of ovulation than standard IUI. The aim of this study was to compare the efficiency of standard intrauterine insemination (IUI) and Fallopian tube sperm perfusion (FSP) in the treatment of non-tubal infertility.

METHODS

200 consecutive patients with infertility in 404 stimulated cycles were included in the study. Those randomized to standard IUI included 100 patients in 184 cycles [158 clomiphene citrate/human menopausal gonadotrophin cycles and 26 Letrozole/FSH cycles exclusively for polycystic ovarian disease patients] (group A). Patients subjected to FSP included 100 patients in 220 cycles (193 clomiphene citrate/human menopausal gonadotrophin cycles and 27 Letrozole/FSH cycles exclusively for polycystic ovarian disease patients] (group B). Swim up semen preparation technique was used in all cases. Insemination was performed in both groups 34-37 h after hCG administration. Standard IUI was performed using 0.5 ml of inseminate. In FSP 4 ml inseminate was used.

RESULTS

In group A (184 IUI cycles in 100 patients), 22 clinical pregnancies (presence of gestational sac with fetal cardiac activity) occurred (11.95% per cycle over four cycles). In group B, (220 cycles of FSP in 100 patients), 48 clinical pregnancies occurred (21.81% per cycle over four cycles) and this difference was statistically significant (p < 0.05).

CONCLUSIONS

For non-tubal sub fertility, the results indicate clear benefit for FSP (Fallopian tube sperm perfusion) over IUI (Intrauterine insemination).

Intra-uterine insemination versus fallopian tube sperm perfusion for non-tubal infertility

BACKGROUND

Controlled ovarian hyperstimulation (COH) combined with intrauterine insemination (IUI) is commonly offered to couples with subfertility that does not involve the fallopian tubes. Another method is fallopian tube sperm perfusion (FSP). This technique ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. The aim of this review was to determine whether FSP and IUI differ in improving the probability of conception.

OBJECTIVES

To investigate whether pregnancy and live birth outcomes differ between fallopian tube sperm perfusion and intrauterine insemination in the treatment of non-tubal subfertility.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Trials Register (October 2008), MEDLINE (January 1966 to October 2008), and EMBASE (January 1988 to October 2008). Abstracts of the American Society for Reproductive Medicine (1987 to 2008) and European Society for Human Reproduction and Embryology (1987 to 2008) meetings were searched using the same key or text words.

SELECTION CRITERIA

Only truly randomised controlled studies comparing FSP with IUI were included in this review. Couples with non-tubal subfertility who have been trying to conceive for at least one year were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials for inclusion based on the quality of the studies.

MAIN RESULTS

Eight studies involving 595 couples were included in the meta-analysis. Only one study reported the live birth rate and there was no evidence of a difference between FSP and IUI (OR 1.2, 95% CI 0.39 to 3.5). There was no evidence of a difference between FSP and IUI for clinical pregnancy per couple (OR 1.2, 95% CI 0.79 to 1.7). A subgroup analysis which included couples with unexplained subfertility only (n = 239) did not report any difference between FSP and IUI (OR 1.6, 95% CI 0.89 to 2.8).

AUTHORS' CONCLUSIONS

For non-tubal subfertility, the results indicate no clear benefit for FSP over IUI. Therefore the advice offered to subfertile couples regarding the comparative use of FSP versus IUI in the treatment of non-tubal subfertility should reflect this.

Comparison of fallopian tube sperm perfusion and intrauterine tuboperitoneal insemination: a prospective randomized study

OBJECTIVE

To evaluate the results of two different methods of insemination: fallopian tube sperm perfusion (FSP) with 4 mL of inseminate and intrauterine tuboperitoneal insemination (IUTPI) with 10 mL of inseminate.

DESIGN

Prospective randomized clinical study.

SETTING

Private infertility center.

PATIENT(S)

Two hundred seventy-six couples, undergoing 403 cycles, with unexplained infertility, mild or moderate male infertility, or mild or moderate endometriosis.

INTERVENTION(S)

Patients were assigned randomly to either FSP (group A, n = 138) or IUTPI (group B, n = 138) treatment. Both groups followed the same mild ovarian stimulation protocol.

MAIN OUTCOME MEASURE(S)

Ninety-five overall pregnancies: 35 in group A (FSP) and 60 in group B (IUTPI).

RESULT(S)

The pregnancy rate per cycle (presence of gestational sac with heart beats) was 17.6% in group A (n = 199) and 29.4% in group B (n = 204). These differences were statistically significant (P < .007). The odds ratio of getting pregnant, per patient, in group B was 2.26 (95% confidence interval 1.36-3.77) compared with group A.

CONCLUSION(S)

The results of this study indicate that IUTPI may prove to be a useful technique in the treatment of unexplained infertility, mild or moderate male infertility, and mild or moderate endometriosis. Three attempts of IUTPI may be beneficial before moving on to more invasive and expensive methods of assisted reproduction techniques.

Intrauterine insemination versus Fallopian tube sperm perfusion in non-tubal subfertility: a systematic review based on a Cochrane review*

BACKGROUND

The objective of this review was to compare the efficacy of Fallopian tube sperm perfusion (FSP) with intrauterine insemination (IUI) in the treatment of non-tubal subfertility.

METHODS

The principles of the Cochrane Menstrual Disorders and Subfertility Group were employed. Only randomized controlled studies comparing FSP with IUI were included in this review. The main outcome measures included live birth rates and pregnancy rates per couple.

RESULTS

Twenty-eight studies were found performing the comparison of interest. Overall six studies involving 474 couples were included in the meta-analysis. One study only assessed live birth rates, which resulted in no difference in outcome between FSP and IUI [odds ratio (OR) 1.17, 95% confidence interval (CI) 0.39-3.53]. The results in pregnancy rate per couple revealed no statistically significant difference between FSP and IUI (OR 1.76, 95% CI 0.77-4.05). Subgroup analysis revealed that couples suffering from unexplained subfertility clearly benefit from FSP over IUI (OR 2.88, 95% CI 1.73-4.78). Excluding studies which used the Foley catheter for tubal perfusion resulted in a significant difference favouring FSP for all indications (OR 2.42, 95% CI 1.54-3.80).

CONCLUSIONS

There is firm evidence that FSP gives rise to higher pregnancy rates in couples with unexplained subfertility and should therefore be advised in these couples. For other indications FSP has not been proven more effective compared with IUI. Results showed that the Foley catheter might not be effective for FSP. Future research should focus on comparing different types of catheters.

Fallopian tube sperm perfusion versus intrauterine insemination in unexplained infertility: a randomized, prospective, cross-over trial

OBJECTIVE

To compare the results of fallopian tube sperm perfusion (FSP) versus standard intrauterine insemination (IUI) in patients with unexplained infertility undergoing controlled ovarian hyperstimulation (COH).

DESIGN

Randomized, prospective, cross-over study.

SETTING

Reproductive medicine unit of a university hospital.

PATIENT(S)

Fifty-six couples with unexplained infertility.

INTERVENTION(S)

COH was induced by recombinant FSH and monitored by serial transvaginal ultrasound. On the day of hCG administration during the first treatment cycle, patients were randomized to either IUI or FSP. Thereafter, in case no pregnancy was achieved, patients went on being treated with FSP and IUI in alternate cycles. A maximum of four treatment cycles per couple was performed. FSP was performed using a pediatric Foley's catheter inseminating 4 mL of sperm-enriched suspension; a Kremer-Delafontaine catheter delivering 0.5 mL of sperm suspension was used for IUI.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per cycle.

RESULT(S)

One hundred twenty-seven cycles (58 FSP, 69 IUI) were performed. The clinical pregnancy rate per cycle was 21.7% for IUI and 8.6% for FSP, respectively. No major adverse effects were recorded for either technique.

CONCLUSION(S)

After COH, FSP is less effective than IUI in couples with unexplained infertility.

Intrauterine insemination versus fallopian tube sperm perfusion for non tubal infertility

BACKGROUND

Controlled ovarian hyperstimulation (COH) together with intrauterine insemination (IUI) is commonly offered to couples with infertility factors not involving the fallopian tubes. Intrauterine insemination gained its popularity because it is simple, non-invasive and cost-effective technique. Another simple non invasive method was introduced called fallopian tube sperm perfusion (FSP). This technique was developed to ensure the presence of higher sperm densities in the fallopian tubes at the time of ovulation than standard IUI provides. Fallopian tube sperm perfusion is based on pressure injection of 4 ml of sperm suspension with attempt of sealing of the cervix to prevent semen reflux. The IUI technique on the other hand is based on intrauterine injection of 0.5 ml of sperm suspension without flushing the tubes. A number of randomised controlled trials have been published comparing the efficacy of FSP with standard IUI. There were considerable variations in the results. The aim of this review was to determine whether outcomes differ between FSP and IUI in improving the probability of conception.

OBJECTIVES

To investigate whether outcomes differ between fallopian tube sperm perfusion and intrauterine insemination in the treatment of non tubal subfertility resulting in pregnancies and live births.

SEARCH STRATEGY

We searched the Menstrual Disorders & Subfertility Group trials register (24 March 2003), MEDLINE (January 1966 to July 2003) and EMBASE (January 1988 to July 2003). Abstracts of the American Society for Reproductive Medicine (1987 to 2003) and European Society for Human Reproduction and Embryology (1987 to 2003) meetings were searched with the same key- or text words.

SELECTION CRITERIA

Only randomised controlled studies comparing fallopian tube sperm perfusion with intrauterine insemination were included in this review. The method of allocation was assessed to determine whether each study was truly randomised or pseudo-randomised. Only first period data of cross-over trials were included for analysis. Couples who have been trying to conceive for at least one year were included but only when the female partner had patent tubes.

DATA COLLECTION AND ANALYSIS

Two independent reviewers (AC and MJ) selected the trials for inclusion based on the quality of the studies.

MAIN RESULTS

Overall six studies involving 474 couples were included in the meta-analysis. Only one study assessed live birth rates (OR 1.17, 95% CI 0.39 3.53). The results for pregnancy rate per couple were statistically significant with FSP showing higher pregnancy rates (OR 1.85, 95% CI 1.23 to 2.79 using the odds ratio with the fixed effect model. To check the results the random effect model was used, which gave a wider confidence interval which crossed the line of no significance (OR 1.76, 95% CI 0.77 to 4.05). As a result, these outcomes should be interpreted with caution. Subgroup analysis revealed that couples suffering from unexplained subfertility benefit from FSP over IUI, resulting in significantly higher pregnancy rates (OR 2.88, 95% CI 1.73 to 4.78). Excluding studies which used the Foley catheter for tubal perfusion resulted in a significant difference favouring FSP for all indications (OR 2.42, 95% CI 1.54 to 3.80).

REVIEWERS' CONCLUSIONS

FSP may be more effective for non-tubal subfertility, but the significant heterogeneity should be taken into account. As a result no advice based on the meta-analysis could be given for the treatment of non-tubal subfertility. Subgroup analysis, which did not show evidence of statistical heterogeneity, suggested that couples with unexplained infertility may benefit from FSP over IUI in terms of higher pregnancy rates. FSP may therefore be advised in couples with unexplained subfertility. Results suggested the possibility of differential effectiveness of FSP depending on catheter choice.