A prospective randomized study of pregnancy rates following intrauterine and intracervical insemination using frozen donor sperm

A low total motile sperm count in donor sperm obtained from commercial banks does not affect pregnancy rates from intrauterine insemination

Objective

Women are often concerned about the absolute quantity and quality of sperm in a thawed donor sample at the time of intrauterine insemination (IUI). The aim of this study was to determine how the total motile sperm count (TMSC) of donor sperm obtained from commercial sperm banks affects the pregnancy rate after IUI.

Study design

We performed a retrospective cohort study including single women and women in same-sex relationships undergoing IUI at a single academic fertility center between January 2011 and March 2018. Our primary outcome was pregnancy rates per IUI cycle, stratified by post-washed TMSC. The data was analyzed according to TMSC and included three different groups: samples with a TMSC less than 5 million; TMSC of 5-10 million; and a TMSC greater than 10 million. Pregnancies were defined by a serum Beta-human chorionic gonadotropin (Beta-HCG) of greater than 5 mIU/mL. Chi-squared analyses and correlation coefficients were performed.

Results

Overall, 9341 IUIs were conducted during the study period. Of these, 1080 (11.56%) were performed for single women and women in a same-sex relationship using commercially available donor sperm. We found that there were no differences in the pregnancy rates per insemination based on TMSC. The pregnancy rates per cycle were 15/114 (13.3%) for the group with a TMSC of less than 5 million; 34/351(9.5%) with a TMSC of 5-10 million; and 61/609 (10.0%) for samples with a TMSC greater than 10 million (p = 0.52). We found an insignificant correlation (r = -0.072) between donor sperm TMSC and pregnancy after IUI (p = 0.46). Furthermore, a reassuring beta-HCG level (>100IU/L) drawn 16 days after IUI was unrelated to TMSC (r = 0.0071, p = 0.94).

Conclusion

The pregnancy rate following IUI is unaffected by the TMSC of commercially available donor sperm. This result is useful in reassuring patients when freshly thawed donor sperm is found to have a lower TMSC. Frozen sperm samples from commercial banks typically represent just a portion of an ejaculate produced by a donor who meets the banks' standards for age, health and sperm quality. As such, exaggerated sperm death caused by freezing does not result in worse outcomes with donor sperm.

Cryopreservation of Gametes and Embryos and Their Molecular Changes

The process of freezing cells or tissues and depositing them in liquid nitrogen at -196 °C is called cryopreservation. Sub-zero temperature is not a physiological condition for cells and water ice crystals represent the main problem since they induce cell death, principally in large cells like oocytes, which have a meiotic spindle that degenerates during this process. Significantly, cryopreservation represents an option for fertility preservation in patients who develop gonadal failure for any condition and those who want to freeze their germ cells for later use. The possibility of freezing sperm, oocytes, and embryos has been available for a long time, and in 1983 the first birth with thawed oocytes was achieved. From the mid-2000s forward, the use of egg vitrification through intracytoplasmic sperm injection has improved pregnancy rates. Births using assisted reproductive technologies (ART) have some adverse conditions and events. These risks could be associated with ART procedures or related to infertility. Cryopreservation generates changes in the epigenome of gametes and embryos, given that ART occurs when the epigenome is most vulnerable. Furthermore, cryoprotective agents induce alterations in the integrity of germ cells and embryos. Notably, cryopreservation extensively affects cell viability, generates proteomic profile changes, compromises crucial cellular functions, and alters sperm motility. This technique has been widely employed since the 1980s and there is a lack of knowledge about molecular changes. The emerging view is that molecular changes are associated with cryopreservation, affecting metabolism, cytoarchitecture, calcium homeostasis, epigenetic state, and cell survival, which compromise the fertilization in ART.

Carboxylated Poly-l-Lysine as a Macromolecular Cryoprotective Agent Enables the Development of Defined and Xeno-Free Human Sperm Cryopreservation Reagents

In human sperm cryopreservation, test yolk buffer and human serum albumin have been used as permeating macromolecular-weight cryoprotectants. In clinical reproductive medicine, human serum albumin is frequently used because of low risks of zoonoses and allergic reactions. However, the risk of allogeneic infectious diseases exists, and the supply may be unstable because human serum albumin is derived from human blood. Therefore, the development of xeno-free human sperm cryopreservative reagents that could overcome the aforementioned problems is warranted. We succeeded in developing a new xeno-free and defined sperm cryopreservation reagent containing glycerol, carboxylated poly-l-lysine, and raffinose. The cryopreservation reagent was not significantly different in terms of sperm motility, viability, and DNA fragmentation and was comparable in performance to a commercial cryopreservation reagent containing human serum albumin. Moreover, the addition of saccharides was essential for its long-term storage. These results may help elucidate the unknown function of macromolecular-weight permeating cryoprotective agents.

Semen evaluation: methodological advancements in sperm quality-specific fertility assessment - A review

Assessment of male fertility is based on the evaluation of sperm. Semen evaluation measures various sperm quality parameters as fertility indicators. However, semen evaluation has limitations, and it requires the advancement and application of strict quality control methods to interpret the results. This article reviews the recent advances in evaluating various sperm-specific quality characteristics and methodologies, with the help of different assays to assess sperm-fertility status. Sperm evaluation methods that include conventional microscopic methods, computer-assisted sperm analyzers (CASA), and flow cytometric analysis, provide precise information related to sperm morphology and function. Moreover, profiling fertility-related biomarkers in sperm or seminal plasma can be helpful in predicting fertility. Identification of different sperm proteins and diagnosis of DNA damage has positively contributed to the existing pool of knowledge about sperm physiology and molecular anomalies associated with different infertility issues in males. Advances in methods and sperm-specific evaluation has subsequently resulted in a better understanding of sperm biology that has improved the diagnosis and clinical management of male factor infertility. Accurate sperm evaluation is of paramount importance in the application of artificial insemination and assisted reproductive technology. However, no single test can precisely determine fertility; the selection of an appropriate test or a set of tests and parameters is required to accurately determine the fertility of specific animal species. Therefore, a need to further calibrate the CASA and advance the gene expression tests is recommended for faster and field-level applications.

Intrauterine insemination versus intracervical insemination in donor sperm treatment

BACKGROUND

The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI).

OBJECTIVES

To compare the effectiveness and safety of intrauterine insemination (IUI) and intracervical insemination (ICI) in women who start donor sperm treatment.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL in October 2016, checked references of relevant studies, and contacted study authors and experts in the field to identify additional studies. We searched PubMed, Google Scholar, the Grey literature, and five trials registers on 15 December 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) reporting on IUI versus ICI in natural cycles or with ovarian stimulation, and RCTs comparing different cointerventions in IUI and ICI. We included cross-over studies if pre-cross-over data were available.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. We collected data on primary outcomes of live birth and multiple pregnancy rates, and on secondary outcomes of clinical pregnancy, miscarriage, and cancellation rates.

MAIN RESULTS

We included six RCTs (708 women analysed) on ICI and IUI in donor sperm treatment. Two studies compared IUI and ICI in natural cycles, two studies compared IUI and ICI in gonadotrophin-stimulated cycles, and two studies compared timing of IUI and ICI. There was very low-quality evidence; the main limitations were risk of bias due to poor reporting of study methods, and serious imprecision.IUI versus ICI in natural cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in natural cycles (odds ratio (OR) 3.24, 95% confidence interval (CI) 0.12 to 87.13; 1 RCT, 26 women; very low-quality evidence). There was only one live birth in this study (in the IUI group). IUI resulted in higher clinical pregnancy rates (OR 6.18, 95% CI 1.91 to 20.03; 2 RCTs, 76 women; I² = 48%; very low-quality evidence).No multiple pregnancies or miscarriages occurred in this study.IUI versus ICI in gonadotrophin-stimulated cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in gonadotrophin-stimulated cycles (OR 2.55, 95% CI 0.72 to 8.96; 1 RCT, 43 women; very low-quality evidence). This suggested that if the chance of a live birth following ICI in gonadotrophin-stimulated cycles was assumed to be 30%, the chance following IUI in gonadotrophin-stimulated cycles would be between 24% and 80%. IUI may result in higher clinical pregnancy rates than ICI (OR 2.83, 95% CI 1.38 to 5.78; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). IUI may be associated with higher multiple pregnancy rates than ICI (OR 2.77, 95% CI 1.00 to 7.69; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). This suggested that if the risk of multiple pregnancy following ICI in gonadotrophin-stimulated cycles was assumed to be 10%, the risk following IUI would be between 10% and 46%.We found insufficient evidence to determine whether there was any clear difference between the groups in miscarriage rates in gonadotrophin-stimulated cycles (OR 1.97, 95% CI 0.43 to 9.04; 2 RCTs, overall 67 pregnancies; I² = 50%; very low-quality evidence).Timing of IUI and ICIWe found no studies that reported on live birth rates.We found a higher clinical pregnancy rate when IUI was timed one day after a rise in blood levels of luteinising hormone (LH) compared to IUI two days after a rise in blood levels of LH (OR 2.00, 95% CI 1.14 to 3.53; 1 RCT, 351 women; low-quality evidence). We found insufficient evidence to determine whether there was any clear difference in clinical pregnancy rates between ICI timed after a rise in urinary levels of LH versus a rise in basal temperature plus cervical mucus scores (OR 1.31, 95% CI 0.42 to 4.11; 1 RCT, 56 women; very low-quality evidence).Neither of these studies reported multiple pregnancy or miscarriage rates as outcomes.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine whether there was a clear difference in live birth rates between IUI and ICI in natural or gonadotrophin-stimulated cycles in women who started with donor sperm treatment. There was insufficient evidence available for the effect of timing of IUI or ICI on live birth rates. Very low-quality data suggested that in gonadotrophin-stimulated cycles, ICI may be associated with a higher clinical pregnancy rate than IUI, but also with a higher risk of multiple pregnancy rate. We concluded that the current evidence was too limited to choose between IUI or ICI, in natural cycles or with ovarian stimulation, in donor sperm treatment.

Chapter 1 Historical Background on Gamete and Embryo Cryopreservation

This chapter describes the development of the science of cryopreservation of gametes and embryos of various species including human. It attempts to record in brief the main contributions of workers in their attempts to cryopreserve gametes and embryos. The initial difficulties faced and subsequent developments and triumphs leading to present-day state of the art are given in a concise manner. The main players and their contributions are mentioned and the authors' aim is to do justice to them. This work also attempts to ensure that credit is correctly attributed for significant advances in gamete and embryo cryopreservation. In general this chapter has tried to describe the historical development of the science of cryopreservation of gametes and embryos as accurately as possible without bias or partiality.

Therapeutic insemination by donor I: A review of its efficacy

Of all the assisted reproductive technologies in current use, artificial insemination has by far the longest history. While the earliest verifiable reports using this technique date to the eighteenth century for nonhuman artificial insemination and to the nineteenth century for human artificial insemination, systematic use of this approach to assist reproduction did not occur until the early part of this century. During the early 1900s, in Russia, Ivanov developed methods for semen collection from and insemination of horses. These techniques were later modified to apply to other agriculturally important species so that by the 1930s, millions of horses, cattle and sheep were being bred using artificial insemination. The adaptation of widespread use of artificial insemination (primarily in cattle) in agriculture extended to Britain in the early 1940s and to the USA in the 1950s. Corresponding implementation of artificial insemination in human reproductive medicine closely followed these innovations in the animal husbandry field.

Cervical insemination versus intra-uterine insemination of donor sperm for subfertility

BACKGROUND

Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples. Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus. Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates.

OBJECTIVES

To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm.

SEARCH STRATEGY

The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved.

SELECTION CRITERIA

Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available.

DATA COLLECTION AND ANALYSIS

Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed.

MAIN RESULTS

The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96).

AUTHORS' CONCLUSIONS

The findings of this systematic review support the use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.

WITHDRAWN: Intra-uterine versus cervical insemination of donor sperm for subfertility

BACKGROUND

Artificial insemination with sperm is used to improve the chances of conception for various causes of infertility. Traditionally, sperm is deposited in or around the endocervical canal (cervical insemination - CI). Some studies reported higher pregnancy rates if sperm was deposited in the uterine cavity itself (intrauterine insemination - IUI), but most were uncontrolled. However the cost and the risks (infection and anaphylaxis) of IUI may also be higher.

OBJECTIVES

The objective of this review was to assess the effects of depositing donor sperm in the uterine cavity (intrauterine insemination) compared to cervical insemination.

SEARCH STRATEGY

The Cochrane Subfertility Review Group specialised register of controlled trials was searched.

SELECTION CRITERIA

Randomised trials comparing intrauterine insemination and cervical insemination, using fresh or cryopreserved semen, with or without ovarian hyperstimulation.

DATA COLLECTION AND ANALYSIS

Trial quality assessment and data extraction were done independently by two reviewers.

MAIN RESULTS

Twelve studies were included. They comprised 697 patients undergoing 2215 treatment cycles. Ten trials used frozen semen, with three using ovarian hyperstimulation. Overall the methodological quality of the trials was low. The overall pregnancy rate per cycle in the intrauterine insemination group was 18% compared to 5% for cervical insemination. When cryopreserved donor sperm was used, the overall chance of pregnancy in spontaneous or clomiphene-corrected cycles was significantly higher with intrauterine insemination. This was irrespective of whether pregnancy rates were calculated on a per cycle (odds ratio 2.63, 95% confidence interval 1.85 to 3.73) or per patient (odds ratio 3.86, 95% confidence interval 1.81 to 8.25) basis. The greatest benefit appeared in trials with poor pregnancy rates (less than 6%) for cervical insemination. There was no difference in pregnancy rate between intrauterine and cervical insemination when fresh donor sperm was used (odds ratio 0.90, 95% confidence interval 0.36 to 2.24).

AUTHORS' CONCLUSIONS

Intrauterine insemination appears to be beneficial when cervical insemination using cryopreserved donor sperm has had low pregnancy rates. This applies to spontaneous, clomiphene corrected and gonadotrophin stimulated cycles. However it may offer little benefit where high pregnancy rates have been achieved with cervical insemination. There appears to be no additional benefit from intrauterine insemination when fresh sperm is used for donor insemination.

Advanced insemination techniques in mares

Advanced artificial insemination techniques, such as deep uterine,hysteroscopic, oviductal, and intrafollicular insemination, are described in the context of the different types of spermatozoa that are now available for insemination, including fresh, chilled, frozen,sex-sorted, and epididymal spermatozoa. The implementation of these new technologies answers and poses questions about the interactions of sperm and oocytes in vivo.

Evidence of improving quality of reporting of randomized controlled trials in subfertility

BACKGROUND

The quality of randomized controlled trials (RCTs) in subfertility and their suitability for inclusion in meta-analyses have been assessed in the past and found to be insufficient. Our aim was to assess whether this quality has improved over time, particularly since the publication of the Consolidated Standards of Reporting Trials (CONSORT) statement, and to assess what proportion of trials could be included in the meta-analyses of pregnancy outcomes such as those included in Cochrane Reviews.

METHODS

A selection of subfertility trials published in 1990, 1996 and 2002 was collected from the Cochrane Menstrual Disorder and Subfertility Group (MDSG) database. Only trials published in English as full journal articles, claiming to be randomized and reporting on pregnancy outcomes, were included.

RESULTS

One hundred and sixty-four trials met our inclusion criteria. Twenty-four (15%) were found not to be randomized, despite claims, and only 10 trials (6%) provided adequate details on the methods of randomization and allocation concealment. Of these, only three had sufficient details extractable to allow for an intention-to-treat analysis of the outcome 'live birth'.

CONCLUSIONS

Although an improvement in some subfertility-specific issues was observed, the quality of reporting of RCTs still needs to improve to make them suitable for inclusion in meta-analyses such as those in the Cochrane Library.

Optimisation des résultats d'inséminations intra-utérines uniques avec sperme de donneur : bilan de quatre ans d'activité

OBJECTIVE

Our aim was to analyse the results of a donor insemination program using ovarian stimulation, swim-up sperm preparation and intrauterine insemination proposed to women with a maximum age of 39. Incidence of several clinical and biological parameters on success rates was investigated.

PATIENTS AND METHODS

Retrospective analysis of the results of 249 cycles performed in 106 couples during a four-year period is reported.

RESULTS

Overall pregnancy rate of 28.1% and delivery rate of 22% per cycle were achieved, with a multiple pregnancy rate of 11.4%. Most of the pregnancies (84%) were obtained before the fourth insemination. Among the different parameters studied the total number of motile sperm inseminated was found to be the most important factor for success rate: pregnancy rate per cycle reached 40.4% if more than 1.5 million progressive sperm were inseminated vs. 24.7% if they were less than 1.5 million (P<0.05).

DISCUSSION AND CONCLUSION

In precise conditions, outcome of inseminations with donor semen can reach satisfying pregnancy rates, being a valuable help for couples suffering of long-time infertility.

The use of urine LH detection kits to time intrauterine insemination with donor sperm

BACKGROUND

The study was carried out to determine the most likely time of day for the onset of the LH surge as detected using urine LH dipsticks, and to calculate the optimum time interval from the onset of the LH surge to intrauterine insemination (IUI).

METHODS

A prospective study of 1540 cycles of IUI with donor sperm at Cleveland Fertility Centre, Middlesbrough, between June 1990 and February 2004. Only 951 cycles (where a positive urine LH dipstick result was immediately preceded by a negative result) were included in our study. To determine the best time interval between the onset of the LH surge and IUI, women were divided into five subgroups according to the positive urine test-IUI time interval and the pregnancy rate and live birth rate per cycle were calculated for each group.

RESULTS

The first positive test was most frequently (44.5%) found at lunch-time (11:00-15:00). The live birth per cycle achieved was 5.6% when the insemination was performed 18-23 h from the first detection of the LH surge, and 11.7% when it was performed between 24 and 42 h. The live birth rate declined to 6.5% when IUI was performed later than that. Overall, no significant differences were discovered in live birth or pregnancy rate when insemination was performed at any of the time points between 18 and 53 h.

CONCLUSION

Our study suggested that lunch-time is the best time to check for the LH surge using urine dipsticks and insemination at any time between 18 and 53 h after the onset of the surge will produce optimal results.

[Artificial insemination with donor frozen sperm]

The cryopreservation of human sperm decreases its fecondity, by reduction in the number of motile sperm. However the fertilizing ability of the spermatozoa is not faded. The use of frozen sperm requires an optimization of the methods of artificial insemination to hope to approach the results obtained with fresh sperm. Intrauterine insemination with sperm selection meets this aim.

Use of semen quality scores to predict pregnancy rates in couples undergoing intrauterine insemination with donor sperm

OBJECTIVE

To establish semen quality scores in a population of sperm donors and determine whether the scores can be used to predict pregnancy rates after donor insemination.

DESIGN

Retrospective study.

SETTING

Infertility clinic at a tertiary care teaching hospital between 1993-2001.

PATIENT(S)

One hundred eleven women who underwent IUI with sperm from 27 anonymous donors.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The semen analysis results before freezing and after thawing were analyzed, and overall donor insemination semen quality (DI-SQ) and donor insemination relative quality (DI-RQ) scores were calculated. After adjusting for female characteristics, the scores were compared with samples that did and did not result in pregnancy.

RESULT(S)

Of 111 patients, 70 had at least one pregnancy, and 60 had at least one live birth, with a mean of 6.52 +/- 4.67 IUI cycles per patient. Five significant risk factors for low pregnancy and live birth rates were identified: female infertility factor, positive laparoscopy, older maternal age, low number of previous births, and lack of ovulatory stimulation. After adjusting for these factors, both prefreeze and postthaw DI-SQ scores were statistically significantly associated with IUI live birth rates. Using only the samples with a DI-SQ score of >110 doubled the expected live birth rate, compared with using samples with a DI-SQ score less than 100, from 8.5% to 16.1%.

CONCLUSION(S)

The DI-SQ score was an effective predictor of pregnancy and live birth outcomes in IUI patients who underwent artificial insemination with anonymous donor semen. The DI-SQ score could also be used by sperm banks to help select donors.

Low dose insemination in the mare: an update

The generally recommended minimum number of spermatozoa required for conventional artificial insemination in the mare is in excess of 200 x 10(6) progressively motile spermatozoa. Recent developments in different insemination techniques such as deep uterine, hysteroscopic and oviductal insemination, which have been designed to use significantly fewer spermatozoa, are reviewed in this paper. A number of studies have demonstrated that ultrasound guided deep uterine insemination of 5 x 10(6) fresh spermatozoa can produce satisfactory pregnancy rates. The use of hysteroscopic insemination enables the insemination dose to be successfully reduced to 1 x 10(6) fresh or 3 x 10(6) frozen-thawed spermatozoa. Further reduction of the insemination dose is possible and satisfactory pregnancy rates can also be achieved by surgical oviductal insemination of mares with as few as 2 x 10(5) fresh spermatozoa. The refinement of these insemination techniques will allow us to maximise the use of frozen-thawed semen, use new technology such as sex-preselection of spermatozoa and to conserve and utilise epididymal spermatozoa at the time of castration or death of a stallion.

Current and future concepts and practices in human sperm cryobanking

This article focuses on a range of issues that are of current concern to those working in human sperm cryobanking and considers them within a general framework of risk analysis and management, taking into account the available evidence and perceptions of 'best practice' from both the medical and legal perspectives. In particular, issues arising from concerns over the risk of cross-contamination between samples during storage immersed in liquid nitrogen have been analysed in detail. Even though such an occurrence has never been reported for spermatozoa or embryos, and the risk is generally accepted to be vanishingly small, it does represent a finite risk and all reasonable measures should be taken to reduce the chance of its occurring. It is concluded that all methods used to collect, cryopreserve, store, thaw and use cryobanked human spermatozoa must address the risk of contamination from any source throughout the entire process. To assist workers in this area, a series of recommendations as to current best practice are made, based upon conclusions from risk analyses using currently available information.

Efficacy of IVF using frozen donor semen in cases of previously failed DI cycles compared with tubal infertility: a cohort study

A cohort follow-up study was designed to compare the efficacy of IVF using frozen donor semen (IVF-D) following previously failed DI cycles (unexplained female infertility) and direct IVF-D treatment because of tubal infertility (control group). The cohort comprised 189 couples initiating IVF-D after previously failed DI cycles (n = 126) or directly (n = 63). Couples were followed until completion (success or drop-out for personal or medical reasons). Live births and drop-out were expressed both as rate per cycle and crude cumulative rate. Characteristics of IVF-D cycles were similar between the two groups. Moreover, overall outcome was also similar in terms of crude cumulative live birth rate (54.0 versus 57.1% for failed DI cycles and tubal infertility groups respectively). This is the first report on crude cumulative live birth rate based on a cohort follow-up study in unexplained previously failed DI cycles and tubal infertility. Previously failed DI cycles did not impair the chances of achieving a successful pregnancy using IVF-D in this series. Slight oocyte dysfunction, which might underlie the failure of DI cycles, might be overcome using IVF-D.

Pregnancy rates in mares after a single fixed time hysteroscopic insemination of low numbers of frozen-thawed spermatozoa onto the uterotubal junction

REASONS FOR PERFORMING STUDY

To compensate for the wide variation in the freezability of stallion spermatozoa, it has become common veterinary practice to carry out repeated ultrasonography of the ovaries of oestrous mares in order to be able to inseminate them within 6-12 h of ovulation with a minimum of 300-500 x 10(6) frozen-thawed spermatozoa. Furthermore, in order to achieve satisfactory fertility, this requirement for relatively high numbers of spermatozoa currently limits our ability to exploit recently available artificial breeding technologies, such as sex-sorted semen, for which only 5-20 x 10(6) spermatozoa are available for insemination.

OBJECTIVES

This study was designed to evaluate and compare the efficacy of hysteroscopic vs. conventional insemination when low numbers of spermatozoa are used at a single fixed time after administration of an ovulation-inducing agent.

METHODS

In the present study, pregnancy rates were compared in 86 mares inseminated once only with low numbers of frozen-thawed spermatozoa (3-14 x 10(6)) at 32 h after treatment with human chorionic gonadotrophin (hCG), either conventionally into the body of the uterus or hysteroscopically by depositing a small volume of the inseminate directly onto the uterotubal papilla ipsilateral to the ovary containing the pre-ovulatory follicle.

RESULTS

Pregnancy rates were similarly high in mares inseminated conventionally or hysteroscopically with 14 x 10(6) motile frozen-thawed spermatozoa (67% vs. 64%). However, when the insemination dose was reduced to 3 x 10(6) spermatozoa, the pregnancy rate was significantly higher in the mares inseminated hysteroscopically onto the uterotubal junction compared to those inseminated into the uterine body (47 vs. 15%, P < 0.05).

CONCLUSIONS

When inseminating mares with <10 x 10(6) frozen-thawed stallion spermatozoa, hysteroscopic uterotubal junction deposition of the inseminate is the preferred method.

POTENTIAL CLINICAL RELEVANCE

Satisfactory pregnancy rates are achievable after insemination of mares with frozen-thawed semen from fertile stallions 32 h after administration of human chorionic gonadotrophin (Chorulon). Furthermore, these results were obtained when mares were inseminated with 14 x 10(6) progressively motile frozen-thawed spermatozoa from 2 stallions of proven fertility.

An overview of low dose insemination in the mare

The need for relatively high numbers of spermatozoa for artificial insemination limits our application of recently available technologies such as sex-sorted semen. The fertility of two different methods of low dose insemination using fresh, frozen and sex-sorted semen are compared in this overview. Satisfactory conception rates are described using very low doses of spermatozoa inseminated by either hysteroscopic or deep uterine insemination methods, proving the stallion is fully fertile. The hysteroscopic method appears to give higher conception rates when inseminating fewer than 5 x 10(6) spermatozoa and is therefore, the preferred method of insemination for sex-sorted spermatozoa. However, hysteroscopic deposition of low numbers of spermatozoa from infertile stallions does not appear to improve their fertility.

Endometriosis: current concepts and therapy

Endometriosis is the growth of endometrial tissue in ectopic locations. The clinical picture is extremely pleiomorphic, which can make the diagnosis difficult. Despite 70 years of theories and experimentation, the cause is not clear, and it is likely that more than one mechanism is at work in most patients. Both medical and surgical treatments are available. In each case, the woman and her physician should formulate a comprehensive treatment plan that addresses the primary complaint as well as the patient's reproductive desires.

Cohort follow-up of couples with primary infertility in an ART programme using frozen donor semen

BACKGROUND

This study was designed to determine the crude cumulative live-birth rates in a cohort initiating frozen donor semen treatment until completion.

METHODS

This cohort study included 588 couples with primary infertility in one University Hospital centre. The treatment sequence involved first artificial insemination (AID) followed by IVF if necessary (IVF-D). Live birth, drop-out for personal or medical reasons and recourse to IVF-D were recorded for all patients. Live births and drop-out were expressed both as rates per cycle and crude cumulative rates.

RESULTS

At the completion of AID and IVF-D cycles, 406 couples in the cohort (69%) achieved a live-birth and 182 couples (31%) discontinued treatment. In most cases, couples stopped treatment for personal reasons (74%) whereas fewer couples were denied further treatment for medical reasons (26%).

CONCLUSIONS

This is the first report on the crude cumulative live-birth rate in a cohort after AID and IVF-D cycles. Although calculation based on crude cumulative live-birth rate shows lower results in comparison with life table analysis, this method allows patients to obtain an insight into their actual chances of achieving a successful pregnancy.

[Is the limitation to 6 cycles of insemination with donor sperm justified?]

OBJECTIVE

To evaluate the effect of the limitation at 6 cycles of artificial insemination in a program of sperm donation.

STUDY DESIGN

266 couples included in a program of sperm donation underwent 1,354 cycles including 532 intracervical insemination (ICI), 678 intrauterine insemination (IUI) and 133 in vitro fertilization (IVF).

RESULTS

The birth rate by cycle was 10.8% in ICI, 18% in IUI, 21.9% in IVF. The risk of multiple pregnancies was 0% in ICI, 13% in IUI, 33% in IVF. The authors feign then two strategies, the first one with 6 ICI followed by 6 IUI, and the other one with 6 IUI alone. The birth rate, the risk of multiple pregnancies and the cost of these two strategies is discussed.

CONCLUSION

The restriction to 6 IA Cycles in a donor semen program does not change the birth rate, but increases the multiple pregnancy rate and the cost of the treatment of these patients.

Computer assisted semen analyzers in andrology research and veterinary practice

The evaluation of sperm cell motility and morphology is an essential parameter in the examination of sperm quality and in the establishment of correlations between sperm quality and fertility. Computer-assisted sperm analysis (CASA) allows an objective assessment of different cell characteristics: motion, velocity, and morphology. The development and problems related to this technology are raised in this review, paying particular attention to the biases and standardization requirements absolutely needed to obtain useful results. Although some interesting results, mainly in humans, have already been obtained, many questions remain, which have to be answered to allow for further development of this technology in veterinary medicine, clinical fertility settings, physiological, and toxicology research activities. The main problem is related to the standardization and optimization of the equipment and procedures. The different CASA instruments have all demonstrated high levels of precision and reliability using different sperm classification methodology. Their availability gives us a great tool to objectively compare sperm motility and morphology and to improve our knowledge and ability to manipulate spermatozoa.

Predictors of success with the use of donor sperm

OBJECTIVE

This study was undertaken to assess the effect of multiple factors that influence the success rate and time to conception among couples undergoing donor sperm insemination.

STUDY DESIGN

A retrospective analysis of 960 cycles of frozen donor sperm insemination was performed at the University of Florida. Cycle pregnancy rates and cumulative probability of pregnancy were compared using several variables.

RESULTS

The pregnancy rate was 12.1% per treatment cycle, and the cumulative probability of pregnancy exceeded 80% for the entire cohort. Seventy percent of pregnancies resulted in a liveborn infant. Age had a profound impact on the cycle pregnancy rate. The cycle pregnancy rates for women younger than 30 years, between the ages of 30 and 35 years, between the ages of 35 and 40 years, and older than 40 years were 15.8%, 14.6%, 8.2%, and 0%, respectively. There was a trend toward higher cycle pregnancy rates in women with prior pregnancies versus women without prior pregnancies of 14.4% and 12.3%, respectively. Parity had no effect on the cycle pregnancy rate or the cumulative probability of pregnancy. There was a trend toward higher cumulative probability of pregnancy in women whose partners were azoospermic versus oligospermic. There was no difference in pregnancy rates obtained with the Percoll wash gradient versus the Isolate gradient. At >20 million total motile sperm per insemination, there was no threshold above which the pregnancy rate was improved.

CONCLUSION

The most significant influence on pregnancy rates in the donor sperm insemination program at the University of Florida was maternal age. Nulligravidity and a diagnosis of mild oligospermia in the man may have a negative impact on pregnancy rates.

A comparison of intrauterine versus intracervical insemination in fertile single women

OBJECTIVE

To compare the efficacy of intrauterine insemination (IUI) and intracervical insemination (ICI) when used by fertile single women in a donor insemination program.

DESIGN

Prospective randomized crossover study.

SETTING

Donor insemination program (not an infertility clinic).

PATIENT(S)

Single fertile women choosing to inseminate with frozen donor semen.

INTERVENTION(S)

Clients received procreative counseling and screening and were then randomly assigned to begin office insemination with ICI or IUI. If additional insemination cycles were required, the clients used the method opposite their previous method of insemination until pregnancy was achieved.

MAIN OUTCOME MEASURE(S)

Monthly fecundity rate was compared between the two methods of insemination.

RESULT(S)

Sixty-two women contributed a total of 189 cycles, 94 by IUI and 95 by ICI. The monthly fecundity rate for IUI was 15%, as compared with 9% for ICI, (P=0.14). When the analysis was confined to cycles in which only one insemination was performed (64 IUI and 65 ICI cycles), the monthly fecundity rates were 14% for IUI and 5% for ICI (P=0.04).

CONCLUSION(S)

Intrauterine insemination with frozen donor sperm is more effective than intracervical insemination for single women without known fertility problems.

[Can donor insemination be optimised?]

OBJECTIVE

To compare the different donor insemination technics.

MATERIAL AND METHOD

Analysis of the published studies about donor insemination which value the effectiveness of Intra Cervical Insemination (ICID) and Intra Uterine Insemination (IUID), the interest of ovulation induction, the possible complications, and the cost-effectiveness ratio.

RESULTS

The meta-analysis of the Cochrane data base (10 comparative studies IUID versus ICID, 2568 donor insemination cycles) lead to a pregnancy rate per cycle (PRC) 17.77% with IUID versus 7.68% with ICID. The odds ratio is 2.63 (CI from 1.85 to 3.73). With these PRC, the direct cost per evolutive pregnancy is 54,780 F with ICID and 25,675 F with IUID.

CONCLUSION

If it is possible to propose ICID to patient with an excellent regularity of ovulation. IUID with ovulation induction by gonadotropins is today the gold standard, and more especially as the law restrict the number of donor inseminations. Indeed, the IUID is two or three times more effective than ICID, consume the half of sperm straws, use a semen of moderate quality, there is no complication provided that the cycle is cancelled if there is more than two mature follicles and the cost-effectiveness ratio is greatly in favour with IUID.

Two different timings of intrauterine insemination for non-male infertility

PURPOSE

Our purpose was to assess the simplicity and convenience of treatment scheduled not on weekends, by comparing two different timings of intrauterine insemination (IUI) protocol.

METHODS

A prospective observational study of two different protocols of intrauterine insemination was designed. Two hundred and ten infertile couples with normal spermiograms were included in this study. Fifty-eight couples were treated with IUI 26 to 28 h after human chorionic gonadotropin (hCG) injection plus timed intercourse within a 12- to 18-hr period and 147 couples had IUI 36 to 38 hr after hCG injection and timed intercourse within a 12- to 18-hour period. Pregnancy rates were compared with two different protocols of IUI.

RESULTS

The mean age, duration, and causes of infertility and the cycle characteristics following follicular stimulation were similar between the two groups. The cycle characteristics of follicular stimulation in the two treatment groups were not different. There also were no significant differences between the groups in the type of sperm concentration, sperm motility, and the percentage of sperm with normal morphology per insemination. The number of follicles greater than 17 mm per patient was not significantly different between the two groups. The pregnancy rate per cycle also was similar between the two groups in men with lower motile sperm numbers (< 40 x 10(6)) (23.6% vs. 23.4%) and in men with higher sperm numbers (> or = 40 x 10(6)) (25% vs. 24.4%).

CONCLUSIONS

The different timing but similar efficacy of these two IUI protocols provides a practical choice to clinicians. The availability of both protocols may avoid unnecessary scheduling of clinical and laboratory work on weekends and holidays in women participating in controlled ovarian hyperstimulation and IUI programs for treatment of non-male infertility.

Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis

OBJECTIVE

To determine whether artificial insemination with frozen donor sperm yielded a higher pregnancy rate per cycle by intracervical (ICI) or intrauterine (IUI) techniques. A meta-analysis was performed.

DATA IDENTIFICATION

A computerized MEDLINE search of the English-language literature on artificial insemination with donor sperm was performed and augmented by a review of meeting abstract books and references in published papers.

STUDY SELECTION

Only prospective randomized studies that reported monthly fecundity rates for IUI and ICI with frozen donor sperm were included.

DATA ANALYSIS

Seven studies were identified. The odds ratios (OR) and 95% confidence intervals (CI) were determined with use of the general estimating equation method for the three studies for which raw data could be obtained. For the remaining four studies, the OR and CI were assessed with use of the published summary data. A random-effects meta-analysis was then performed.

RESULT

Intrauterine insemination resulted in a significantly higher monthly fecundity rate with a common OR of 2.4 (CI 1.5-3.8).

CONCLUSION

On the basis of this meta-analysis of the seven prospective studies, IUI results in higher pregnancy rates than ICI for frozen donor insemination.

Early resort to ovarian stimulation improves the cost-effectiveness of a donor insemination programme

Women undergoing donor insemination (DI) are usually regularly ovulating, therefore the role of ovulation induction in this modality of treatment has been controversial. Some recent studies reported higher pregnancy rates in stimulated cycles in comparison with natural cycles. We employed a sequential step-up protocol in which treatment was started in a natural cycle, continued with a clomiphene citrate-stimulated cycle, and finished with an ovulation induction cycle. The patients were allowed three attempts at each step before moving to the next if conception did not occur. The aim of this protocol was to enhance the cost-effectiveness of the DI programme by increasing the cycle fecundability. A total of 101 patients underwent 216 cycles of DI, including 44 patients in 80 natural cycles, 38 patients in 89 CC-stimulated cycles, and 19 patients in 47 ovulation induction cycles. The clinical pregnancy rate per started cycle (CPR/C) and per patient during this period was 14% and 30% respectively. The pregnancy rates per started cycle and per patient in the natural, CC-stimulated and ovulation induction cycles were: 13 and 32%, 10 and 18%, and 21 and 53% respectively. There was no significant difference in the CPR/C in the three groups; however, the CPR per patient in the induced ovulation cycles was significantly higher than in the CC-stimulated cycles (P = 0.005). Only one patient during this period had a multiple pregnancy in the ovulation induction group, giving an overall multiple pregnancy of 3%. By using this treatment strategy, we achieved a high clinical pregnancy rate, a low multiple pregnancy rate and a low cost of treatment per pregnancy.

Fecundability trends among sperm donors as a measure of donor performance

OBJECTIVE

To examine fecundability trends among sperm donors.

DESIGN

Retrospective analysis.

SETTING

University-based sperm bank and donor insemination program.

PATIENT(S)

Sperm donors and recipients.

INTERVENTION(S)

A group of recipients underwent IUI with cryopreserved donor sperm. Fecundability was calculated for 20 sperm donors over 800 insemination cycles.

MAIN OUTCOME MEASURE(S)

Average fecundability per donor was compared for the first 40 cycles of a donor's use and for those donors within a group of more fertile recipients. Sperm parameters, recipient ages, and number of unique recipients for each donor were analyzed.

RESULT(S)

Average donor fecundability is constant; however, individual donors demonstrated differences among their fecundabilities (overall mean, 0.09; range, 0.01-0.26). These differences persisted for donors among a group of more fertile recipients (overall mean, 0.12; range, 0.02-0.35). A donor's fecundability at 15 cycles is predictive of his future performance.

CONCLUSION(S)

Differences in fecundability exist among sperm donors which cannot be discerned through routine semen parameters. Sperm donor fecundability should be analyzed periodically, and directors of sperm banks should consider discontinuing use of a donor whose outcome is substandard.

Does transcervical intra-fallopian insemination improve pregnancy rates in cases of oligoteratoasthenozoospermia? A prospective, randomized study

The relatively low pregnancy rates (PR) after treatment of patients with oligoteratoasthenozoospermia (OTA) result in a search for different treatment modalities. The objective of this study was to assess the efficacy of transcervical intrafallopian insemination (IFI) with husband's semen in comparison to intrauterine insemination (IUI) in couples with OTA. A prospective, randomized study included 30 couples with OTA-related infertility (according to WHO criteria). The female patients underwent individually adjusted controlled ovarian stimulation by gonadotropins. Spermatozoa was prepared using the Percoll 70% technique and insemination was performed 36-40 h after human chorionic gonadotropin (HCG) administration. The Tomcat Catheter was used for IUI and the Jansen-Anderson Catheter for IFI to the fallopian tube leading to the ovary that contained more dominant follicles. The couples were divided according to sperm count, into group A (9 couples): < 10 mill ml-1 and group B (21 couples): > 10 mill ml-1. Within the groups the patients were randomly assigned for IUI or IFI treatment. Among group B couples, two pregnancies out of 15 IUI cycles (13.3% PR) and two pregnancies out of 18 IFI cycles (11.1% PR) were achieved. Group A patients completed 7 IUI and 9 IFI treatment cycles with no pregnancies observed. These data did not demonstrate a statistically significant advantage for either technique.

Timed intercourse after intrauterine insemination for treatment of infertility

OBJECTIVE

To compare the pregnancy rates, between intrauterine insemination (IUI) followed by timed intercourse and IUI only for treatment of the infertile couples.

STUDY DESIGN

A prospective study of two different protocols of intrauterine insemination in two hundred and one infertile couples with a normal spermiogram was carried out. Of these, 101 couples were treated with IUI alone and 100 couples had both IUI and timed intercourse within a 12-18 h period. The pregnancy rates were compared between groups.

RESULTS

The characteristics of the two groups were similar in terms of the mean age, as well as the duration and causes of infertility. The cycle characteristics following follicular stimulation were also similar between two groups. The pregnancy rate per cycle increased with increasing numbers of total motile sperm per insemination in the IUI alone group (P=0.045). Timed intercourse increased pregnancy rate in patients with lower motile sperm number (<40x10(6)) (27.7% versus 10.5%, P=0.023), but not in patients with higher sperm number (> or =40x10(6)) (25.7% versus 22.7%, P=0.671).

CONCLUSIONS

In IUI with low number of motile sperm inseminated, timed intercourse significantly increases the pregnancy rates over IUI alone in infertile couples with a normal sperminogram. This alternative treatment appears to be a practical, simple, and inexpensive addition that improves the pregnancy rate in patients receiving ovulation induction and intrauterine insemination program.

Intrauterine insemination: is it an effective treatment for male factor infertility?

Results were collected from 11 studies comparing intrauterine insemination (IUI) with intracervical insemination (ICI) of frozen donor semen, 10 studies comparing IUI with timed natural intercourse (NI) or ICI in couples with semen defects and seven studies comparing ICI with NI or ICI in couples with unexplained infertility. IUI significantly increased the pregnancy rate relative to favourably timed ICI in donor insemination (DI) with frozen semen both with and without gonadotrophin stimulation of the female partner (odds ratios (95% confidence interval) 1.92 (1.02-3.61) and 2.63 (1.52-4.54) respectively). The benefit of IUI tended to be less when the pregnancy rate for ICI was high and IUI had no benefit with fresh donor semen. Overall IUI was of significant benefit in the male factor couples compared with NI-ICI (odds ratio 2.20 (1.43-3.39) and the advantage appeared to be maintained when comparison was confined to properly timed ICI although the odds ratios were not significantly greater than 1. IUI had no benefit relative to favourably timed NI-ICI for couples with unexplained infertility; an apparent advantage overall was produced by studies where NI was late. None of the studies on male factor used a sperm function test to define male subfertility and three only included couples with good mucus penetration by sperm. The range of semen defects defined was such that many couples would have had a good chance of conceiving naturally given a normal female partner but nevertheless the overall pregnancy rate (4.8%) was considerably less than in the unexplained group (11.6%), suggesting that some sperm dysfunction was present. We conclude that the available evidence suggests that IUI is valuable for DI with cryopreserved semen and for couples with mild to moderately impaired semen quality and postulate that it overcomes failure to fertilize due to impaired mucus penetration and poor survival in the female reproductive tract.

Effects of cryopreserved semen quality and timed intrauterine insemination on pregnancy rate and gender of offspring in a donor insemination program

PURPOSE

Our purpose was to study the relationship among cryopreserved donor semen quality, pregnancy rates, and preconception sex selection after intrauterine insemination.

METHODS

We reviewed the records of the 203 women in our donor insemination program from 1987 to 1994 who became pregnant after more than one insemination cycle and had no female-factor infertility. They were categorized according to the number of cycles required for pregnancy. Semen samples from 54 donors were analyzed before freezing and after thawing. Specimens resulting in pregnancy were compared to specimens from the same donor that did not. Semen characteristics were compared to gender of the child.

RESULTS

Two hundred fifty two-women became pregnant of the 422 who were enrolled. The pregnancy rate per cycle was 13%. Semen quality was not related to pregnancy outcome or offspring gender. However, more male children (101 vs 83) were born.

CONCLUSIONS

Semen characteristics in good-quality cryopreserved donor semen do not affect pregnancy rate or offspring gender.

Comparison of the role of cervical and intrauterine insemination techniques on the incidence of multiple pregnancy after artificial insemination with donor sperm

PURPOSE

Our purpose was to investigate the role of the insemination technique used in an artificial insemination program with donor sperm (AID) in multiple pregnancy rates.

METHODS

We carried out a retrospective nonrandom analysis of 300 pregnancies corresponding to 300 cycles in women from our Artificial Insemination Donor Sperm Program. All cycles were stimulated with gonadotropins. Single and multiple pregnancy cycles and intracervical and intrauterine pregnant cycles were compared.

RESULTS

Intracervical insemination was performed in 173 cycles (58%), and intrauterine insemination in 127 (42%). Two hundred twenty-three pregnancies were single (74%), and 77 multiple (26%). In multiple pregnancy cycles, initial dose and mean total daily dose of gonadotropins, plasma estradiol levels, and number of follicles > or = 14 mm were significantly higher compared to those in single pregnancy cycles. Multiple pregnancy rte was significantly higher among pregnancies after intrauterine insemination (32%) than after intracervical insemination (21%).

CONCLUSIONS

The intrauterine technique of insemination in AID-stimulated cycles with gonadotropins is related to multiple pregnancy risk.