Effect of diagnosis, age, sperm quality, and number of preovulatory follicles on the outcome of multiple cycles of clomiphene citrate-intrauterine insemination

Intrauterine Insemination (IUI) Outcomes With Total Progressive Motile Sperm Count (TPMSC) Above and Below 5 Million

OBJECTIVE

The study aims to investigate the impact of total progressive motile sperm count (TPMSC) on pregnancy outcomes in couples diagnosed with unexplained infertility undergoing intrauterine insemination (IUI).

MATERIALS AND METHODS

A retrospective analysis was conducted on 122 IUI cycles from 98 couples with unexplained infertility who received treatment at Zeynep Kamil Women's and Children's Diseases Training and Research Hospital between 2021 and 2022. The couples were divided into two groups based on TPMSC: below 5 million and 5 million or above. Key pregnancy outcomes, including chemical pregnancy, clinical pregnancy, and live birth rates, were evaluated and compared between the groups.

RESULTS

Of the 122 IUI cycles analyzed, 69 had a TPMSC of 5 million or above, and 53 cycles had a TPMSC below 5 million. The chemical pregnancy, clinical pregnancy, and live birth rates were significantly higher in the group with TPMSC above 5 million (34.8%, 31.9%, and 23.2%, respectively) compared to the TPMSC below 5 million group, which had no pregnancies. The findings demonstrate that TPMSC is a critical predictor of IUI success, with a TPMSC threshold of 5 million associated with significantly higher pregnancy outcomes.

CONCLUSION

This study highlights that a TPMSC below 5 million is associated with poor IUI outcomes, suggesting that IUI may not be a cost-effective treatment for couples with severe oligoasthenospermia. For these couples, alternative treatments like in vitro fertilization (IVF) may be more appropriate. The findings provide valuable insights for improving the management and treatment strategies for unexplained infertility.

Pregnancy among Women Undergoing Intrauterine Insemination in a Centre

Introduction

Intrauterine insemination is often performed as the first-line treatment option in many subfertility cases. Successful intrauterine insemination treatment among indicated couples helps to reduce unnecessary in-vitro fertilisation treatment. Although widely practised, the data on pregnancy after intrauterine insemination treatment is limited. The aim of this study was to find out the prevalence of pregnancy among women undergoing intrauterine insemination in a centre.

Methods

A descriptive cross-sectional study was conducted at a centre among women undergoing intrauterine insemination. Data from 15 May 2017 to 15 April 2021 were collected between 16 June 2022 to 1 July 2022 from the hospital records. Ethical approval was taken from the Nepal Health Research Council. Systematic sampling technique was applied to select the appropriate sample. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 225 women undergoing intrauterine insemination, pregnancy was achieved in 23 (10.22%) (6.26-14.18, 95% Confidence Interval). The mean age of pregnant women was 29.17±3.34 years and the mean duration of infertility was 3.93±2.90 years. More than half of the pregnant women 13 (56.52%) had undergone insemination with the husband's semen whereas the remaining 10 women (43.48%) had undergone insemination with donor semen.

Conclusions

The prevalence of pregnancy among women undergoing intrauterine insemination was similar to other studies done in similar settings.

Keywords

artificial insemination; Nepal; pregnancy rate.

Optimal lead follicle size in letrozole human menopausal gonadotrophin intrauterine insemination cycles with and without spontaneous LH surge

RESEARCH QUESTION

What is the optimal lead follicle size in letrozole, human menopausal gonadotrophin and intrauterine insemination (IUI) cycles with and without spontaneous LH surges?

DESIGN

This retrospective cohort study included 3797 letrozole HMG IUI cycles between January 2010 and May 2021. All cycles were divided into two groups: the HCG trigger group (trigger day LH ≤15 mIU/ml) and the spontaneous LH surge group (trigger day LH >15 mIU/ml). These two groups were subdivided into smaller groups based on the diameter of the follicles. The primary outcome measure was clinical pregnancy rate. Logistic regression analysis was conducted to explore other risk factors.

RESULTS

In the HCG trigger group, the clinical pregnancy rate varied significantly, with rates of 20.8%, 14.9% and 11.8% for the 16.1-18.0, 18.1-20.0 and 20.1-22.0 mm groups, respectively (P = 0.005). In the spontaneous LH surge group, the pregnancy rate of follicles within 14.1-16.0 mm was significantly higher than that of follicles within 20.1-22.0 mm (adjusted OR 0.533, 95% CI 0.308 to 0.923, P = 0.025). Also, patients with two lead follicles were 2.569 times more likely to achieve a clinical pregnancy than those with only one lead follicle (adjusted OR 2.569, 95% CI 1.258 to 5.246, P = 0.010). The duration of infertility was also found to be a common influencing factor in both groups.

CONCLUSIONS

The optimal lead follicle size was between 16.1 and 18.0 mm in HCG-triggered letrozole HMG IUI cycles. If the lead follicle size is relatively small (14.1-18.0 mm) when a spontaneous LH surge occurs, there is no need to cancel the IUI cycle.

Pregnancy outcomes after oral and injectable ovulation induction in women with infertility with a low antimüllerian hormone level compared with those with a normal antimüllerian hormone level

OBJECTIVE

To determine the ongoing pregnancy rate among patients with infertility with a low antimüllerian (AMH) level compared with those with a normal AMH level after oral and injectable ovulation induction (OI)/intrauterine insemination (IUI).

DESIGN

Retrospective cohort.

SETTING

Academic center.

PATIENT(S)

Patients completing ≥1 medicated OI/IUI cycle at our center between 2015 and 2019 were included. The AMH levels were measured within 12 months of treatment initiation. The cohort was stratified into low AMH (AMH level, <1.0 ng/mL) and normal AMH (AMH level, ≥1.0 ng/mL) groups. All subsequent medicated OI/IUI cycles occurring within 1 year of initial cycle start date were included up to the third completed cycle or until an ongoing pregnancy was recorded. Patients were stratified by age (<35, 35-40, and >40 years), and the relationship between the low and normal AMH groups and each binary endpoint were quantified as risk ratios using the age-adjusted Poisson models.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy.

RESULT(S)

A total of 3,122 patients completed 5,539 oral antiestrogen cycles, and 1,060 completed 1,630 injectable gonadotropin cycles. For oral antiestrogen treatment, pregnancy outcomes, including ongoing pregnancy rate per cycle, for patients with a low AMH level were comparable with those for patients with a normal AMH level (<35 years, 15.4% vs. 14.9%; 35-40 years, 10.0% vs. 11.0%; and >40 years, 2.8% vs. 3.3%). For injectable gonadotropin treatment, the ongoing pregnancy rate was lower in the low AMH group than in the normal AMH group for the ages of <35 (12.1% vs. 23.5%; relative risk [RR], 0.52 [95% confidence interval {CI}, 0.28-0.97]) and 35-40 (12.5% vs. 18.5%; RR, 0.70 [95% CI, 0.49-0.99]) years but comparable with that for patients aged >40 years (3.0% vs. 4.0%; RR, 0.86 [95% CI, 0.31-2.35]). The proportion of multifetal gestations was similar between the low and normal AMH groups treated with oral antiestrogens (13.1% vs. 10.8%); however, for injectable gonadotropin treatment, patients with a normal AMH level had a higher proportion of multifetal gestations (18.6% vs. 31.1%).

CONCLUSION(S)

Compared with normal ovarian reserve, treatment with oral antiestrogens for OI/IUI for patients with low ovarian reserve results in comparable follicular development and ongoing pregnancy rates for all age groups. When patients with low ovarian reserve are treated with gonadotropins for OI/IUI, multifollicular recruitment is less likely resulting in a significantly decreased ongoing pregnancy rate for patients aged <35 and 35-40 years but also a decrease in multifetal gestations. Overall, the ongoing pregnancy rates of 8.7% per oral antiestrogen cycle and 8.1% per injectable gonadotropin cycle in patients with low ovarian reserve are comparable with the expected rates in the general infertility population.

Optimizing pregnancy outcomes in intrauterine insemination cycles by stratifying pre-wash total motile count and patient-specific factors: a patient counseling tool

PURPOSE

The purpose of this study is to clarify which pre-wash total motile count are associated with improved clinical pregnancy rate (CPR) and live birth rate (LBR) based on maternal age, AMH level, stimulation regimen, and infertility diagnosis.

METHODS

This was a retrospective cohort study of first completed IUI cycles at two academic fertility centers from 5/2015 to 9/2019. Cycles were stratified by pre-wash TMC, maternal age, AMH level, stimulation regimen, and infertility diagnosis. The primary outcome was CPR and secondary outcomes were live birth and miscarriage.

RESULTS

One thousand one hundred fifty-four cycles were analyzed. Of the 162 cycles that resulted in a CPR (14.0%), most had an insemination TMC > 20 million. Compared to TMC > 20 million, there was no difference in CPR or LBR for lower TMC categories, excluding the TMC < 2 million group, in which there were no pregnancies. When TMC was stratified by deciles, there was also no difference in CPR and LBR, including within the lowest decile (TMC 0.09-8.6 million). Younger age and higher ovarian reserve parameters were associated with higher pregnancy and LBR when stratified by TMC. There was no difference in pregnancy and LBR when considering different stimulation protocols.

CONCLUSIONS

Our data suggest that pregnancy and LBR are equivalent above a TMC of 2 million. Data stratified by TMC and patient parameters can be used to counsel patients pursuing ART.

Predicting success of intrauterine insemination using a clinically based scoring system

Purpose

To develop a predictive score for the success of intrauterine insemination (IUI) based on clinical parameters.

Methods

We performed a retrospective cohort study evaluating the homologous IUI cycles performed at a single university-based reproductive medical center between 2009 and 2017. The primary outcome measure was pregnancy, defined as positive serum human chorionic gonadotropin (hCG) 12–14 days after IUI. Predictive factors for pregnancy after IUI were identified, and a predictive score was developed using a multivariable continuation ratio model.

Results

Overall, 1437 IUI cycles in 758 couples were evaluated. We found a per cycle pregnancy rate of 10.9% and a cumulative pregnancy rate of 19.4%. In a multivariable analysis, the probability of pregnancy was negatively associated with female age ≥ 35 years (OR 0.63, 95% CI 0.41–0.97, p = 0.034), endometriosis, unilateral tubal factor, or anatomical alteration (OR 0.54, 95% CI 0.33–0.89, p = 0.016), anti-Mullerian hormone (AMH) < 1 ng/ml (OR 0.50, 95% CI 0.29–0.87, p = 0.014), and total progressive motile sperm count (TPMSC) < 5 mil (OR 0.47, 95% CI 0.19–0.72, p = 0.004). We developed a predictive clinical score ranging from 0 to 5. Following 3 cycles, couples in our cohort with a score of 5 had a cumulative probability of achieving pregnancy of nearly 45%. In contrast, couples with a score of 0 had a cumulative probability of only 5%.

Conclusion

IUI success rates vary widely depending on couples’ characteristics. A simple to use score could be used to estimate a couple’s chance of achieving pregnancy via IUI, facilitating individualized counseling and decision-making.

Ovulation induction and intrauterine insemination in women of advanced reproductive age: a systematic review of the literature

PURPOSE

The objective of this review is to define live birth rate (LBR) and clinical pregnancy rate (CPR) for women ≥ 40 undergoing ovulation induction (OI)/intrauterine insemination (IUI).

METHODS

A systematic review was performed in accordance with PRISMA guidelines using PubMed and Google Scholar. The primary and secondary outcomes of interest were LBR and CPR, respectively.

RESULTS

There were 636 studies screened of which 42 were included. In 8 studies which provided LBR for partner sperm, LBR/cycle ranged from 0 to 8.5% with majority being ≤ 4%. Cumulative LBR was 3.6 to 7.1% over 6 cycles with the majority of pregnancies in the first 4. In the four studies providing LBR for donor sperm cycles, LBR/cycle ranged from 3 to 7% with cumulative LBR of 12 to 24% over 6 cycles. The majority of pregnancies occurred in the first 6 cycles. There were three studies with LBR or CPR/cycle ≥ 1% for women ≥ 43. No studies provided data above this range for women ≥ 45. In 4 studies which compared OI/IUI and IVF, the LBR from IVF was 9.2 to 22% per cycle. In 7 studies which compared outcomes by stimulation protocol, no significant differences were seen.

CONCLUSION

For women ≥ 40 using homologous sperm, the highest probability of live birth is via IVF. However, if IVF is not an option, OI/IUI may be considered for up to 4 cycles in those using partner sperm or 6 cycles with donor sperm. For women > 45, OI/IUI is likely futile but a limited trial may be considered for psychological benefit while encouraging consideration of donor oocyte IVF or adoption. Use of gonadotropins does not appear to be more effective than oral agents in this age group.

Should intrauterine inseminations still be proposed in cases of unexplained infertility? Retrospective study and literature review

OBJECTIVE

Unexplained infertility is defined by the absence of identifiable causes of infertility. The results of randomized studies and meta-analysis regarding the treatment of unexplained infertility are discordant due to methodological problems.

DESIGN

The aim of this study is to compare the clinical pregnancy rate per cycle (CPR/c) in IUI and IVF/ICSI in cases of unexplained infertility, according to the woman's age group and to identify the factors which predict success.

INTERVENTIONS

We performed a retrospective study in two ART centers, comparing overall clinical pregnancy, ongoing pregnancy and live birth rates in IVF/ICSI and IUI. We also compared pregnancy and birth rates according to different female age groups.

RESULTS

855 IVF/ICSI and 804 IUI cycles were compared. We found a significant difference (p < 0.001) in the pregnancy and live birth rates per cycle between IUI and IVF/ICSI, overall and in the different female age groups, except in women aged 40 and over. The greatest chances of pregnancy with IUI are found in women with secondary unexplained infertility, during the first two cycles and with a bi-follicular response to stimulation. In IVF/ICSI, pregnancy rates are higher in women with secondary unexplained infertility, in the first two cycles, in IVF and in women receiving a transfer of two embryos regardless of the embryonic stage.

CONCLUSION

We recommend IVF/ICSI treatment rather than IUI for unexplained infertility (OR CPR/c 4.20 with 95% CI [3.72-4.68]). This is in accordance with NICE, which advises the use of IVF after 2 years.

The pregnancy outcomes of infertile women with polycystic ovary syndrome undergoing intrauterine insemination with different attempts of previous ovulation induction

BACKGROUND

Polycystic ovary syndrome (PCOS) is one of the most common reasons for infertility. The consensus of the treatment of infertile women with PCOS is ovulation induction (OI) for six to nine attempts before in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Nowadays, more attention was paid to a rising, noninvasive treatment, intrauterine insemination (IUI), as some experts claimed IUI could benefit PCOS patients with infertility. Our study means to investigate the outcomes of IUI for PCOS patients and if patients' previous OI cycles can be a predictive factor for IUI outcomes.

METHODS

A total of 1,086 PCOS patients was included and 1,868 IUI cycles were performed between January 2007 and July 2021 in the department of assisted reproduction in Shanghai Ninth People's Hospital. All included patients underwent IUI treatments with letrozole+human menopausal gonadotropin (LE+hMG) for ovarian stimulation.

RESULTS

The pregnancy outcomes were not associated with the attempts of failed OI cycles previously. Specifically, the clinical pregnancy rate was 21.14% for PCOS patients without previous OI cycles, 21.95% for PCOS patients with 1-2 previous OI cycles and 23.64% for PCOS patients with 3 or more previous OI cycles (p=0.507). The corresponding live birth rate was 16.64%, 18.06%, and 18.68%, respectively, of which the difference was not statistically significant (p=0.627). The cumulative rate per patient was 38.59% for clinical pregnancy and 31.03% for live birth, and approximately 98% of the pregnancies occurred in the first 3 cycles of IUI.

CONCLUSION

PCOS women with different attempts of OI cycles had similar pregnancy outcomes after IUI, thus a history of repeated failures of OI treatments was not a predictive factor for the pregnancy outcomes in IUI cycles. Most pregnancies occurred in the first three cycles of IUI, so we strongly recommended three attempts of IUI for PCOS women before they switched to IVF/ICSI. Generally, IUI might be an assist for infertile women with PCOS before IVF/ICSI and might accelerate pregnancy for target women without invasive manipulations.

Pregnancy outcomes following different protocols of controlled ovarian hyperstimulation in couples undergoing intrauterine insemination

Clomiphene citrate (CC), letrozole and cetrorelix acetate are frequently used agents in controlled ovarian hyperstimulation (COH). However, these three agents have not yet been compared to one another regarding their pregnancy outcomes. The present study was designed to retrospectively compare pregnancy outcomes among the three aforementioned agents. This study involved infertile couples with an infertility duration of at least 2 years, ages 18 to 42 years and who were referred to have their first intrauterine insemination (IUI) treatment cycle. All patients underwent COH with recombinant follicle-stimulating hormone (rFSH) plus CC (n = 118), letrozole (n = 81), or cetrorelix acetate (n = 62), followed by IUI. Using the one-way multivariate analysis of covariance to control female patients' ages, patients stimulated with cetrorelix acetate/rFSH or CC/rFSH had higher numbers of preovulatory follicles than women stimulated with letrozole/rFSH (P < .02), whereas women stimulated with cetrorelix acetate/rFSH had a thicker endometrium than women stimulated with CC/rFSH (P < .0005). Biochemical pregnancy rates were similar among the three protocols of COH. However, women stimulated with letrozole/rFSH showed clinical pregnancy rates higher than those stimulated with CC/rFSH (P = .003) or cetrorelix acetate/rFSH (P = .03) and subclinical abortion rates lower than those stimulated with CC/rFSH or cetrorelix acetate/rFSH (P = .009). Of the different protocols of COH, the odds of having a clinical pregnancy was 3.1 times greater for women stimulated with letrozole/rFSH than women stimulated with CC/rFSH (P = .004) and 2.8 times greater for women stimulated with letrozole/rFSH than women stimulated with cetrorelix acetate/rFSH (P = .03). Our observations show that increased numbers of preovulatory follicles or endometrium thickness do not necessarily improve pregnancy outcomes, because pregnancy outcomes are also subjected to the type of COH used agent. In this regard, letrozole produced fewer preovulatory follicles and did not significantly increase endometrium thickness, but significantly improved pregnancy outcomes in comparison to CC and cetrorelix acetate.

Predictive factors for intrauterine insemination outcomes: a review

PURPOSE

Intrauterine insemination (IUI) is a frequently utilized method of assisted reproduction for patients with mild male factor infertility, anovulation, endometriosis, and unexplained infertility. The purpose of this review is to discuss factors that affect IUI outcomes, including infertility diagnosis, semen parameters, and stimulation regimens.

METHODS

We reviewed the published literature to evaluate how patient and cycle specific factors affect IUI outcomes, specifically clinical pregnancy rate, live birth rate, spontaneous abortion rate and multiple pregnancy rate.

RESULTS

Most data support IUI for men with a total motile count > 5 million and post-wash sperm count > 1 million. High sperm DNA fragmentation does not consistently affect pregnancy rates in IUI cycles. Advancing maternal and paternal age negatively impact pregnancy rates. Paternal obesity contributes to infertility while elevated maternal BMI increases medication requirements without impacting pregnancy outcomes. For ovulation induction, letrozole and clomiphene citrate result in similar pregnancy outcomes and are recommended over gonadotropins given increased risk for multiple pregnancies with gonadotropins. Letrozole is preferred for obese women with polycystic ovary syndrome. IUI is most effective for women with ovulatory dysfunction and unexplained infertility, and least effective for women with tubal factor and stage III-IV endometriosis. Outcomes are similar when IUI is performed with ovulation trigger or spontaneous ovulatory surge, and ovulation may be monitored by urine or serum. Most pregnancies occur within the first four IUI cycles, after which in vitro fertilization should be considered.

CONCLUSIONS

Providers recommending IUI for treatment of infertility should take into account all of these factors when evaluating patients and making treatment recommendations.

Pregnancy Predictors after Intrauterine Insemination in Cases of Unexplained Infertility: A Prospective Study

Introduction. Aim of the study was to find the effect of various prognostic factors in cases of unexplained infertility undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI). Methods. 146 cases of unexplained infertility were included. A maximum of 3 cycles of IUI were done with clomiphene citrate/HMG. Ovulation trigger was given when the largest follicle diameter was >18 mm, and IUI was planned 36 hours later. Luteal phase support was given for 15 days, urine pregnancy test was done on day 15, ultrasonography was done at 7 weeks, and pregnancy was followed up till delivery. Results. A total of 146 couples have undergone 239 cycles of IUI out of which 27 had UPT positive after 15 days. 14.8% had 1st-trimester abortion while 3.7% were ectopic. 86.3% were singleton pregnancies and 13.6% were twins. CPR was 11.29% per cycle and 18.4% per couple; LBR was 9.2% per cycle. Apart from duration of stimulation (p = 0.037) and number of treatment cycles (p = 0.045), no other factors had significant prognostic value. Conclusion. For unexplained infertility, IUI can be done to provide patients with the time that they need before moving on to IVF while providing a respectable chance of pregnancy.

Factors affecting clinical pregnancy rates after IUI for the treatment of unexplained infertility and mild male subfertility

OBJECTIVE

The aim of the present retrospective study was to evaluate intrauterine insemination (IUI) clinical experiences and to define the variables for predicting success.

MATERIAL AND METHODS

The present study was an observational trial performed in a private IVF center on subfertile couples who had applied for treatment between 2002 and 2012, in which the data of 503 IUI cases were retrospectively reviewed. Couples who had been diagnosed with unexplained and mild male subfertility were included. The primary outcome measure was the clinical pregnancy rate in an attempt to form a predictive model for the odds of a clinical pregnancy. Recorded parameters were used to determine the prediction model.

RESULTS

Utilizing univariate logistic regression analysis, clinical pregnancy was positively associated with the duration of infertility (OR=1.09, p=0.089), secondary infertility (OR=1.77, p=0.050), and +4 sperm motility after preparation (OR=1.03, p=0.091). Following an adjustment analysis involving a multivariate logistic regression, clinical pregnancy was still found to positively associate with secondary infertility (OR=2.51, p=0.008).

CONCLUSION

IUI success in secondary infertile couples who were in the unexplained infertility and mild male subfertility groups was higher than that in primary infertile couples, and the chances of pregnancy increased as sperm numbers with +4 motility increased. It is difficult to concomitantly evaluate all these parameters and to determine a predictive parameter in IUI independent from other factors.

Mono-ovulation in women with polycystic ovary syndrome: a clinical review on ovulation induction

Polycystic ovary syndrome (PCOS) affects 5-10% of women of reproductive age and is the most common cause of anovulatory infertility. The treatment approaches to ovulation induction vary in efficacy, treatment duration and patient friendliness. The aim was to determine the most efficient, evidence-based method to achieve mono-ovulation in women diagnosed with PCOS. Publications in English providing information on treatment, efficacy and complication rates were included until September 2015. Systematic reviews, meta-analyses and randomized controlled trials were favoured over cohort and retrospective studies. Clomiphene citrate is recommended as primary treatment for PCOS-related infertility. It induces ovulation in three out of four patients, the risk of multiple pregnancies is modest and the treatment is simple and inexpensive. Gonadotrophins are highly efficient in a low-dose step-up regimen. Ovulation rates are improved by lifestyle interventions in overweight women. Metformin may improve the menstrual cycle within 1-3 months, but does not improve the live birth rate. Letrozole is effective for ovulation induction, but is an off-label drug in many countries. Ovulation induction in women with PCOS should be individualized with regard to weight, treatment efficacy and patient preferences with the aim of achieving mono-ovulation and subsequently the birth of a singleton baby.

Predicting suitable timing for artificial reproductive technology treatment in aged infertile women

It has been widely accepted that the age of women plays a fundamental role in fecundity, and age-related fertility decline has one of the most significant and detrimental effects on the success rate of infertility treatment. Therefore, treatment cycles of non-in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment for infertile women of advanced aged have been limited due to their lack of efficacy, and they are often optimized, compared to IVF/ICSI treatment. Recent trends in infertility treatment apparently indicate that IVF/ICSI treatment, including egg donation, is frequently offered to aged women for first-line management, despite its heavy burden, but hasty IVF/ICSI treatment should be avoided, considering its socioeconomic problems. It is important to distinguish women who could conceive by non-IVF/ICSI treatment, although the optimization of non-IVF/ICSI treatment protocols remains poorly understood. This review focuses on extracting aged patients who have higher chance of conceiving with non-IVF/ICSI treatment and providing necessary and sufficient infertility treatment. After initial evaluation for fertility, including tubal factor, male factor, the presence of endometriosis and/or adenomyosis, and ovarian reserve, the outcomes of fertility treatment can be predicted to some extent in aged infertile women.

Comparison of pregnancy rates in PCOS patients undergoing clomiphene citrate and IUI treatment with different leading follicular sizes

PURPOSE

The objective of the study was to compare the pregnancy rates in PCOS patients undergoing clomiphene citrate (CC) and intrauterine insemination (IUI) treatment with different leading follicular sizes.

METHODS

A total of 358 infertile women with PCOS who underwent 563 clomiphene citrate and IUI treatment cycles were included in this prospective study. Treatment cycles were divided into three groups according to leading follicular size on the day of hCG administration: Group I: follicular size 17-18 mm (n = 177), Group II: 19-22 mm (n = 321), and Group III : >22 mm (n = 65). Pregnancy rates were evaluated. Treatment outcomes of the groups were further analyzed related to endometrial thickness measurement on the day of hCG. For this purpose, cycles were placed into three subgroups as follows: endometrial thickness <7, 8-9, and >9 mm.

RESULTS

There was no statistically significant difference in clinical pregnancy rate per cycle between the groups (8.5, 10, and 9.2 % for Group I, II, and III, respectively, p = 0.86). In further analyses related to endometrial thickness, no significant difference was also found in pregnancy rate among the groups.

CONCLUSION

This results suggest that pregnancy rate is not related to leading follicle size on the day of hCG administration in PCOS patients treated with CC and IUI. In addition, pregnancy rate in women with different follicular sizes is not influenced by the endometrial thickness.

Evaluating The Effective Factors in Pregnancy after Intrauterine Insemination: A Retrospective Study

Background

Controlled ovarian hyperstimulation (COH) in conjunction with intrauterine inseminations (IUI) are commonly used to treat infertile couples. In this study we evaluated the relationship between IUI outcome and special causes of infertility. We also aimed to examine parameters that might predict success following IUI.

Materials and Methods

In this cross-sectional study, we included 994 IUI cycles in 803 couples who referred to the infertility Institute. All statistical analyses were performed by using SPSS program, t tests and chi-square. Stepwise multiple linear regression analysis was performed to compare the association between dependent and independent variables. Logistic regression was conducted to build a prediction model of the IUI outcome.

Results

Overall pregnancy rate per completed cycle (16.5%) and live birth rate per cycle (14.5%). The mean age in the pregnant group was significantly lower than that of the non-pregnant group (P=0.01).There was an association between cause of infertility and clinical pregnancies (P<0.001). Logistic regression identified four significant factors in determining the success of the IUI [menstrual irregularites (OR:2.3, CI:1.6-3.4, P<0.001), duration of infertility (OR:0.8, CI:0.8-0.9, P<0.001), total dose of gonadotropin (OR:1.02, CI:1.003-1.04, P=0.02) and semen volume (OR:1.1, CI:1.008-1.2, P=0.03)] which were the most predictive of IUI success.

Conclusion

Our study defined prognostic factors for pregnancy in COH+IUI. These variables can be integrated into a mathematical model to predict the chance of pregnancy rate in subsequent COH+IUI cycles.

Outcomes after intrauterine insemination are independent of provider type

OBJECTIVE

We sought to determine whether the success of intrauterine insemination (IUI) varies based on the type of health care provider performing the procedure.

STUDY DESIGN

This was a retrospective cohort study set at an infertility clinic at an academic institution. The patients who comprised this study were 1575 women who underwent 3475 IUI cycles from late 2003 through early 2012. Cycles were stratified into 3 groups according to the type of provider who performed the procedure: attending physician, fellow physician, or registered nurse (RN). The primary outcome was live birth. Additional outcomes of interest included positive pregnancy test and clinical pregnancy. Repeated measures log binomial regression was used to estimate the risk ratios (RR) and 95% confidence intervals (CI) for the outcomes and to evaluate the effect of potential confounders. All tests were 2-sided, and P values < .05 were considered statistically significant.

RESULTS

Of the 3475 IUI cycles, 2030 (58.4%) were gonadotropin stimulated, 929 (26.7%) were clomiphene citrate stimulated, and 516 (14.9%) were natural. The incidences of clinical pregnancy and live birth among all cycles were 11.8% and 8.8%, respectively. After adjusting for female age, male partner age, and cycle type, the incidence of live birth was similar for RNs compared with attending physicians (RR, 0.80; 95% CI, 0.58-1.1) and fellow physicians compared with attending physicians (RR, 0.84; 95% CI, 0.58-1.2). Similar results were seen for positive pregnancy test and clinical pregnancy.

CONCLUSION

There was no significant difference in live birth following IUI cycles in which the procedure was performed by a fellow physician or RN compared with an attending physician.

Should IVF be used as first-line treatment or as a last resort? A debate presented at the 2013 Canadian Fertility and Andrology Society meeting

Infertility outcomes can be influenced by many factors. Although a number of treatments are offered, deciding which one to use first is a controversial topic. Although IVF may have superior efficacy in achieving a live birth with a reasonable safety profile, the availability of cheaper and less invasive treatments preclude its absolute use. For this reason, certain patient groups with 'good-prognosis' infertility are traditionally treated with less invasive treatments first. 'Good-prognosis' infertility may include unexplained infertility, mild male factor infertility, stage I or II endometriosis, unilateral tubal blockage and diminished ovarian reserve. Here, evidence behind the use of IVF as a first-line treatment is compared with its use as a last-resort option in women with 'good-prognosis' infertility.

Factors influencing the outcome of intrauterine insemination (IUI): age, clinical variables and significant thresholds

The aim was to investigate the influence of various biological factors upon the outcome of intrauterine insemination (IUI). The total IUI history (856 cycles) of 352 couples was studied. Live-birth showed a strong negative correlation with female age but no correlation with male age. Antimüllerian hormone (AMH) and antral follicle count (AFC) correlated negatively with female age, and follicle stimulating hormone (FSH) correlated positively. Significant thresholds were found for all three variables, and also for total motile count (TMC) in the prepared sperm. Calculating pregnancy losses per positive pregnancy showed a strong correlation with increasing female age. This was highly significant for biochemical losses but not for fetal heart miscarriages. Male age had no effect on rate of pregnancy loss. In conclusion, female age, FSH, AMH and TMC are good predictive factors for live-birth and therefore relate to essential in vivo steps in the reproductive process.

Success in pregnancy through intrauterine insemination at first cycle in 300 infertile couples: an analysis

OBJECTIVE

The aim of this article was to determine digital levels of the association of factors of pregnancy success after the first cycle of intrauterine insemination (IUI) with 300 infertile couples.

METHODS

The IUI procedure was followed at 36 h after triggering the ovulation, if at least one follicle measured >15 mm. Endometrium thickness (ET) and serum luteinizing hormone (LH) levels were measured at day 10 for each patient. The post-wash total motile fraction (TMF) of semen of the partner of each patient was also evaluated. The principal component analysis (PCA) was done with the data to quantify the associations of related factors.

RESULTS

The clinical pregnancy rate of first cycle IUI attempts was 17.3 %, observed in females, aged 20-39 years and men with TMF >5 million spermatozoa. The ovarian stimulation enabled the development of follicles measuring >16 mm, with LH levels <10 mIU/L and ET >5 mm for success. The PCA revealed that with the female-age parameter, three factors, NF, ET, and LH were related in the component 1; similarly, NF, LH, and RFS were related in component 2; age, NF, ET, LH, LFS, and TMF were related in component 3; and NF, ET, LH, RFS, and LFS in component 4 were related, i.e., the best correlation.

CONCLUSIONS

Associated principal determinative factors, LH, female-age, NF and LFS values were highly significant, but the factors, ET, RFS and TMF were statistically insignificant for success through IUI in pregnancy.

Patient-specific predictions of outcome after gonadotropin ovulation induction/intrauterine insemination

OBJECTIVE

To use patient-specific and cycle-specific characteristics to predict clinical pregnancy, multiple pregnancy, and spontaneous abortion rates after gonadotropin ovulation induction (OI)/IUI.

DESIGN

Retrospective chart review.

SETTING

Academic fertility center.

PATIENT(S)

A total of 1,438 women who underwent 3,375 gonadotropin OI/IUI cycles.

INTERVENTION(S)

Individual and cycle-specific characteristics were evaluated to determine predictors of the rates of clinical pregnancy, multiple pregnancy, and spontaneous abortion. Logistic regression using individual parameters was used to create predictive models.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy (CPR), multiple pregnancy (MPR), and spontaneous abortion rates (SABR).

RESULT(S)

Multiple predictors were identified for CPR, MPR, and SABR. The presence of at least two follicles ≥ 13 mm at ovulation trigger significantly increased CPR (odds ratio [OR], 95% confidence interval [CI] = 1.45, 1.18-1.78) and MPR (OR, 95% CI = 5.17, 2.16-12.41). An E2 level >400 pg/mL significantly increased MPR (OR, 95% CI = 9.54, 2.31-39.42). Logistic regression models were developed for individualized predictions of outcome.

CONCLUSION(S)

Regression analysis reveals the patient and cycle-specific characteristics that are significant predictors of CPR, MPR, and SABR after OI/IUI. Logistic models using significant or nearly significant predictors for CPR, MPR, and SABR offer improved predictive power relative to simpler models, and allow for the development of a risk calculator for personalized patient counseling.

Prognosis factors of pregnancy after intrauterine insemination with the husband's sperm: conclusions of an analysis of 2,019 cycles

OBJECTIVE

To identify the prognostic factors for pregnancy after intrauterine insemination with the husband's sperm (IUI-H).

DESIGN

Retrospective study.

SETTING

A single university medical center.

PATIENT(S)

851 couples, for 2,019 IUI-H cycles.

INTERVENTION(S)

After controlled ovarian stimulation, IUI-H performed 36 hours after ovulation triggering or 24 hours after a spontaneous luteinizing hormone (LH) surge.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per cycle (PR) and delivery rate per cycle (DR).

RESULT(S)

The overall PR was 14.8% and DR 10.8%. Higher PR and DR were observed for patients presenting with ovulation disorders (particularly polycystic ovary syndrome) or with male infertility. Secondary infertility in the woman appeared to be a positive prognostic factor as did a basal follicle-stimulating hormone (FSH) level ≤ 7 IU/L and ovulation triggering over spontaneous LH rise. The other parameters influencing the results were the women's age, the number of mature follicles obtained (≥ 2), the endometrial thickness (10-11 mm), and the number of progressive motile spermatozoa inseminated (>1 million).

CONCLUSION(S)

In women aged ≤ 38 years, IUI-H should be considered as an option, particularly in cases of female infertility from ovulation disorders, in cases of a normal ovarian reserve, in cases of secondary infertility, or when ≥ 1 million progressive sperm are inseminated. Bifollicular stimulation is required. In other cases, in vitro fertilization should be discussed as the first-line treatment.

Predictive factors for pregnancy during the first four intrauterine insemination cycles using gonadotropin

PURPOSE

Although a variety of factors have been reported as affecting pregnancy rates after intrauterine insemination (IUI), there have been conflicting results on prognostic factors. This study aimed to determine predictive factors for pregnancy in patients undergoing the first four IUI cycles.

METHODS

A total of 348 IUI cycles using clomiphene citrate or letrozole combined with gonadotropin, or gonadotropin only were analyzed. Baseline clinical characteristics, variables related to ovulation induction and sperm parameters were compared between pregnant (n = 54) and non-pregnant groups (n = 294). Logistic regression analysis was performed to identify factors that could predict a pregnancy.

RESULTS

The overall clinical pregnancy rate was 15.5% (54/348) per cycle and 30.0% (54/180) per couple. During the first four IUI cycles, logistic regression analysis revealed that woman who were 39 years or older (OR: 0.263, 95% CI: 0.076-0.906, p = 0.034), longer duration of infertility (OR: 0.967, 95% CI: 0.942-0.993, p = 0.012), endometriosis (versus unexplained infertility; OR: 0.177, 95% CI: 0.040-0.775, p = 0.022) and endometrial thickness below 7 mm (OR: 0.114, 95% CI: 0.015-0.862, p = 0.035) were unfavorable factors to predict clinical pregnancy.

CONCLUSIONS

Women with old age, longer duration of infertility, the presence of endometriosis or thin endometrium in the preovulatory phase may have unfavorable outcomes during the first four IUI cycles.

Effectiveness of GnRH antagonist in intrauterine insemination cycles

OBJECTIVE

To evaluate the effectiveness of GnRH antagonists in women undergoing controlled ovarian stimulation and intrauterine insemination cycles (COS/IUI).

STUDY DESIGN

Randomized controlled trial. Recruited women were randomized into two groups: GnRH antagonist and control group. The primary outcomes were incidence of premature LH surge and clinical pregnancy rates.

RESULTS

One hundred and forty-one consecutive women were included in the study, with 70 in the antagonist group and 71 in the control arm. The baseline clinical characteristics were similar in both groups. The incidence of premature LH surge and premature luteinization was lower in the antagonist group as compared to the control group (5% vs. 10.3%, P=0.45 and 5% vs. 13.8, P=0.31) but not statistically significant. The clinical pregnancy rates were lower in the antagonist group (2.8% vs. 10%, P=0.12), which was also not statistically significant.

CONCLUSION

The addition of GnRH antagonist during controlled ovarian stimulation and intrauterine insemination cycles does not lead to improvement in clinical pregnancy rates.

Fundamental role of folliculo-luteal function in recurrent miscarriage

PURPOSE

To re-evaluate the role of folliculo-luteal function (FLF) in recurrent miscarriage (RM) on the basis of new hormonal diagnostic criteria.

METHODS

A prospective, randomized, single-blinded, placebo-controlled study was carried out at 110 apparently healthy patients with three or more miscarriages not related to any presumable predisposing factors of RM were investigated. In the treatment group FLF was normalized preconceptionally. Women in the control group received placebo. FLF was regarded as physiological when the mean of three progesterone (P) values measured every second day between the 4th and 9th day after ovulation or before menstruation was 21.0 ± 2.0 ng/ml.

RESULTS

A significant difference (p < 0.001) was found between the physiological and placebo groups in the occurrence of live births: 93 versus 56 %, pregnancy losses: 7 versus 44 %; premature delivery per births: 10 versus 57 %. Luteal mean P and estradiol values were significantly (p < 0.001) different in cases of spontaneous abortions and premature and mature deliveries, respectively (P: 14.6 ± 2.2, 20.2 ± 2.7, 27.6 ± 3.9 ng/ml). A strong and significant correlation (p < 0.001) was found between luteal mean P values and the duration of pregnancy (r = 0.85), as well as between the P means measured in the luteal phase and different parameters of the newborns: weight (r = 0.89), weight percentile (0.86) and length (0.73). Retrospective analysis of our data suggests that a luteal P mean value of 29.3 ± 2.9 ng/ml characterising patients with singular, mature, eutroph newborns seems to be the most favorable P value for successful reproduction in RM.

CONCLUSION

Determining the oocyte quality and placentation, FLF quantitatively determines the outcome of pregnancy: its duration and different characteristics of the newborns in RM.

Predictive factors for pregnancy after intrauterine insemination: A prospective study of factors affecting outcome

OBJECTIVE:

To determine the predictive factors for pregnancy after controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI).

DESIGN:

Prospective observational study.

SETTING:

University-level tertiary care center.

PATIENTS AND METHODS:

366 patients undergoing 480 stimulated IUI cycles between November 2007 and December 2008.

INTERVENTIONS:

Ovarian stimulation with gonadotrophins was initiated and a single IUI was performed 36 h after triggering ovulation.

MAIN OUTCOME MEASURES:

The primary outcome measures were clinical pregnancy and live birth rates. Predictive factors evaluated were female age, duration of infertility, indication for IUI, number of preovulatory follicles, luteinizing hormone level on day of trigger and postwash total motile fraction (TMF).

RESULTS:

The overall clinical pregnancy rate and live birth rate were 8.75% and 5.83%, respectively. Among the predictive factors evaluated, the duration of infertility (5.36 vs. 6.71 years, P = 0.032) and the TMF (between 10 and 20 million, P = 0.002) significantly influenced the clinical pregnancy rate.

CONCLUSION:

Our results indicate that COH/IUI is not an effective option in couples with infertility due to a male factor. Prolonged duration of infertility is also associated with decreased success, and should be considered when planning treatment.

[Significance of insemination in the era of IVF and ICSI]

The first step in the treatment of infertile couples in most cases is the method of intrauterine insemination (IUI), as it is less invasive than the extracorporeal procedures of ART (artificial reproductive techniques). However, in comparison to the methods of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), IUI is discussed controversially, especially in terms of effectiveness and efficacy, for the result of IUI is influenced by multiple factors. Thus, not only methodological aspects, e.g. preparation of and insertion of the prepared sperm into the genital tract, time of insemination in relation to ovulation, but also the reasons for female subfertility and sperm quality have to be taken into consideration.Based on current literature and practical experience there are some prerequisites to be fulfilled to recommend IUI: It should only be applied in couples with female age under 40 years, known tubal status, short period of infertility and on the male side unrestricted or only slightly restricted sperm parameters, ideally normozoospermia. IUI is the method of choice versus timed intercourse and should be set up together with gonadotrophin ovarian stimulation. The step up to ART procedures should follow after four cycles of unsuccessful IUI at the latest. In terms of cost-effectiveness, efficacy and benefit of detailed information on germ cell material and embryo development, it must rather be recommended to switch to IVF/ICSI as soon as possible.

The effectiveness of clomiphene citrate in LH surge suppression in women undergoing IUI: a randomized controlled trial

OBJECTIVE

To study the effectiveness of clomiphene citrate (CC) in preventing a premature LH surge during controlled ovarian stimulation in women undergoing assisted reproduction.

DESIGN

Prospective, randomized, controlled trial.

SETTING

University hospital.

PATIENT(S)

Two-hundred thirty couples with mild male factor, or unexplained infertility.

INTERVENTION(S)

Couples were randomized to receive human menopausal gonadotrophins (hMG) followed by CC or hMG alone until the day of hCG.

MAIN OUTCOME MEASURE(S)

The primary outcomes were the incidence of a clinical pregnancy and premature LH rise. Secondary outcomes were the E2 levels, number of mature follicles, and endometrial thickness as determined on the day of hCG.

RESULT(S)

The number of patients who had a premature LH surge was significantly lower in the hMG+CC group (5.45% vs. 15.89%). Additionally, the mean E2 levels (pg/mL) and the number of mature follicles were also significantly higher in the hMG+CC group (360.3±162.9 vs. 280±110.0 and 2.4±0.97 vs. 1.3±1.1, respectively), although there was no significant difference regarding number of canceled cycles, endometrial thickness, or clinical pregnancy rate.

CONCLUSION(S)

The addition of CC to hMG has been proven to be effective in reducing premature LH surges without compromising the pregnancy rate.

Cetrorelix lowers premature luteinization rate in gonadotropin ovulation induction-intrauterine insemination cycles: a randomized-controlled clinical trial

Attempting to compare the rates of premature luteinization (PL), clinical pregnancy, and cycle cancellation in ovulation induction-intrauterine insemination (OI-IUI) cycles with and without the GnRH antagonist, cetrorelix, a randomized-controlled trial was undertaken in which patients were randomized to one of two OI-IUI protocols. Those in the cetrorelix arm showed a significantly reduced rate of PL and no change in clinical pregnancy or cycle cancellation rate, leading to the conclusion that GnRH antagonists can decrease the rate of PL, but appear to have no effect on pregnancy or cycle cancellation in gonadotropin OI-IUI cycles.

Offering excess oocyte aspiration and vitrification to patients undergoing stimulated artificial insemination cycles can reduce the multiple pregnancy risk and accumulate oocytes for later use

BACKGROUND

The prevention of multiple pregnancies remains a major challenge in patients treated with ovarian stimulation prior to intrauterine insemination (IUI). The pilot study presented here investigates whether multiple pregnancies can be minimized by a microscopically confirmed aspiration of oocytes from supernumerary follicles immediately before intrauterine insemination and evaluates the benefit of concomitant excess oocyte cryopreservation for future use.

METHODS

Thirty-four aspirations of supernumerary follicles were performed immediately prior to IUI in 31 patients undergoing ovarian stimulation. sIUI was only performed if cumulus-oocyte complexes were microscopically observed in the aspirated follicular fluid. All collected mature excess oocytes were cryopreserved using the vitrification technique.

RESULTS

Only four sIUI procedures had to be cancelled due to failed oocyte retrieval or premature ovulation. IUI treatment resulted in a clinical pregnancy rate of 23.5% per cycle. All were singleton pregnancies. A total of 111 oocytes were cryopreserved. Patients with polycystic ovary syndrome (PCOS) had an average of 6.07 oocytes vitrified, whereas patients without PCOS had 1.3 oocytes vitrified per cycle.

CONCLUSION

Microscopically confirmed collection of excess oocytes prior to stimulated IUI reduced cancellation rates, further reduced the risk for multiple pregnancy and may lead to future additional pregnancies because, based on current information, approximately 5% of the vitrified oocytes could potentially establish a pregnancy.

Asian ethnicity is associated with decreased pregnancy rates following intrauterine insemination

Asian ethnicity has been associated with decreased pregnancy outcomes in patients undergoing IVF. The objective of this study was to determine if a difference exists in pregnancy rates between Asian and Caucasian patients undergoing intrauterine insemination (IUI). A retrospective cohort of Asian and Caucasian patients treated with IUI between December 2002 and 2006 was analysed, including 2327 IUI cycles among 814 patients. Baseline characteristics were similar between Asian and Caucasian women. A significantly greater proportion of Asians (43.9%) presented for treatment after more than 2 years of infertility compared with Caucasians (24.6%) (P < 0.0001). Unadjusted analysis showed a trend towards decreased pregnancy rates associated with Asian ethnicity (odds ratio (OR) 0.71, 95% CI 0.50-1.01, not significant). Age, stimulation protocol, differences in gravity and parity, and duration of infertility did not account for this difference (adjusted OR 0.68, 95% CI 0.47-0.98, P = 0.039). Asian ethnicity is associated with lower pregnancy rates in IUI treatment. The increased duration of infertility in Asians does not explain the reduced pregnancy rates.