Clomiphene citrate with intrauterine insemination: is it effective therapy in women above the age of 35 years?

Overview of infertility

Having a child is an innate trait in animals, including humans, and is required for the continued existence of all animal species. Therefore, for most women, the inability to conceive or to do so in a timely fashion - termed infertility - to enable the continuation of the family line can be emotionally distressing. The definition of infertility is controversial because of its separation into primary and secondary. This is further complicated by the loosely used term subfertility, which relates to couples who have reduced ability because they take longer than the natural time to conceive, as opposed to those who are infertile and are entirely unable to conceive after 6 to 12 months, depending on age. Infertility evaluation requires a thorough male and female history, physical examination of both partners, and targeted investigation to determine the cause of infertility in a particular couple. Various treatments apply to infertile couples depending on the age of the female partner, the results of investigations, the reason for infertility, the presence of inheritance of abnormal genes, the pregnancy rates the couple is happy with, the resources available, how desperate the couple is to achieve a live birth, and how much they want to commit to treatment. Infertility treatment could include counseling and expectant management only, intrauterine insemination in a natural or stimulated cycle, and IVF and or ICSI. Men with azoospermia will need surgical options to retrieve sperm for IVF/ ICSI, but rarely for IUI. This review overviews infertility's etiology, diagnosis, investigations, and treatment.

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.

The role of anti-Mullerian hormone in predicting the response to clomiphene citrate in unexplained infertility

OBJECTIVE

To determine the role of anti-Mullerian hormone (AMH) levels in predicting the response to clomiphene citrate (CC) therapy for ovulation induction in women with unexplained infertility.

MATERIALS AND METHODS

For this retrospective study, fifty consecutive patients who responded to CC were taken as Group 1, while fifty consecutive patients who failed to show adequate ovulatory response with CC were taken as Group 2. We compared the AMH levels of the two groups and receiver operating characteristic (ROC) curve was used to determine the threshold for AMH in predicting the ovulatory response to CC therapy.

RESULTS

Mean age, body mass index, luteinizing hormone, prolactin, and thyroid-stimulating hormone values were similar in the two groups. AMH and antral follicle count (AFC) values were higher in Group 1 than in Group 2 (p = 0.001 and p = 0.001, respectively). There was a statistically significant negative correlation between FSH and AFC (r = -0.339, p = 0.001), while AFC and AMH displayed a statistically significant positive correlation (r = 0.713 and p = 0.001). AMH values and AFC were found to be predictors of the adequate ovulatory response to CC. The area under the ROC curve was 0.86 vs 0.80, respectively. At an AFC cutoff value of 14, the sensitivity and specificity for prediction of ovulation were 68% and 80%, respectively.

CONCLUSION

The AMH and AFC cut-off values for the prediction of positive ovarian response to CC in patients with unexplained infertility were 2.78 ng/mL and 14, respectively. If further prospective and randomized studies confirm our results, these thresholds may be useful to predict successful ovulation induction and reduce the unresponsive cycles.

Minimal stimulation using gonadotropin combined with clomiphene citrate or letrozole for intrauterine insemination

PURPOSE

To evaluate the efficacy of minimal stimulation using discretely administered gonadotropin combined with clomiphene citrate (CC) or letrozole (LTZ) for intrauterine insemination (IUI) cycles.

MATERIALS AND METHODS

Total 257 IUI cycles from 158 infertile couples were assessed. A CC dose of 100 mg/day (n=126 cycles) or a LTZ dose of 5 mg/day (n=131 cycles) was administered on days 3-5 of the menstrual cycle for 5 days. Each group received human menopausal gonadotropin at a dose of 150 IU by two or three alternative day: CC combined with alternate-day regimen for 2 or 3 days (CC+300, n=37; CC+450, n=89) and LTZ combined with alternate-day regimen for 2 or 3 days (LTZ+300, n=36; LTZ+450, n=95).

RESULTS

The clinical pregnancy rate was comparable between the CC and LTZ groups (18.3% vs. 13.0%, p=0.243). The clinical pregnancy rate also showed no significant difference among the 4 groups (21.6% vs. 16.9% vs. 11.1% vs. 12.6%, p=0.507). The multiple pregnancy rate was significantly higher in LTZ compared to CC group (37.5% vs. 8.7%, p=0.028) and in the LTZ+450 compared to CC+450 group (50% vs. 13.3%, p=0.038). Overall, there were 15 cases of ovarian hyperstimulation syndrome (OHSS), with the prevalence being significantly lower in the LTZ compared to CC group (1.5% vs. 10.3%, p=0.003). OHSS was more prevalent in the CC+450 compared to the LTZ+450 group (12.4% vs. 1.1%, p=0.002).

CONCLUSION

Our findings suggest that minimal stimulation using two alternate-day gonadotropin with LTZ decreases the development of OHSS and multiple pregnancies, while maintaining comparable pregnancy rates in IUI cycles.

A "four-cycle program" improves the estimate of the cumulative pregnancy rate and increases the number of actual pregnancies in IUI treatment: a cohort study

OBJECTIVE

To demonstrate that reduction of the cumulative dropout rate (CDR) improves the accuracy of the estimate of the cumulative pregnancy rate (CPR) in a set of four intrauterine insemination (IUI) cycles ("four-cycle program") and increases the total number of pregnancies obtained.

STUDY DESIGN

Single-centre retrospective observational cohort study of couples who underwent IUI cycles at the Andros Day Surgery Clinic, Palermo, from 1997 to 2011. The main outcome measure was the calculation of the CPR, with life table analysis, firstly by giving the same probability of pregnancy to the dropouts as the patients who continued the treatment (usual method) and secondly by considering this probability null (conservative method). The difference between these two methods was used to verify the accuracy of the estimate.

RESULT(S)

In the 15 years, 924 couples underwent 2956 cycles carried out consecutively in a set of four cycles. The CDR was 16%. The CPR was 31.4% with the usual method and 29.1% with the conservative method. The difference between the two estimates was not significant, indicating a high reliability of the results and a good accuracy of the calculation. Furthermore, maintenance of a low CDR permits improvement of the CPR, as was demonstrated by considering scenarios with worse dropout rates.

CONCLUSION(S)

The "four-cycle program" results in a reduction in the CDR, allowing a better estimation of the CPR, and increases the number of actual pregnancies in IUI. The CPR should become the focus for reporting outcome rates in IUI cycles. Reduction of the dropout rate allows us to give the patient a more reliable and accurate estimate of the pregnancy rate.

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.

Strategies to reduce multiple pregnancies due to ovulation stimulation

OBJECTIVE

To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence.

DESIGN

Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented.

RESULT(S)

High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles.

CONCLUSION(S)

High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.

Stimulated intrauterine insemination (SIUI) and donor insemination (DI) as first line management for a selected subfertile population: the Manchester experience

PURPOSE

The objective of our study is to investigate the optimum number of stimulated intrauterine insemination (SIUI) or donor insemination (DI) cycles that can be offered to the couples prior to in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in a tertiary referral unit for assisted reproduction.

METHODS

This is a retrospective analysis of 408 SIUI and 704 DI cycles performed in a tertiary referral unit for assisted reproduction. SIUI's were performed by controlled ovarian hyperstimulation and ovulation induction followed by insemination 36 h later. DI's were performed in natural or stimulated cycles after thawing frozen donor sperm. The main outcome measured was cumulative live birth rate (CLBR) per couple.

RESULTS

A maximum CLBR of 26.1% was achieved after the fourth cycle of SIUI. The CLBR of DI increased to 60.1% in the sixth cycle.

CONCLUSIONS

This study, in line with a number of other studies, is unable to demonstrate unequivocally whether increasing numbers of IUI or DI cycles are justified clinically or financially. There is a need for larger datasets from multiple centres along with rigorous randomised trials to compare treatment pathways. Until then, the resources spent on the provision of extra SIUI cycles may be better utilized by early referral to IVF.

Donor insemination and infertility: what general urologists need to know

Therapeutic donor insemination (TDI), also known as artificial insemination by donor, is one of the oldest forms of male infertility treatment. With the advent of assisted reproductive technologies and in vitro fertilization techniques over the past few decades, the use of TDI in male infertility treatment has decreased dramatically. Knowledge of its use, indications, efficacy, and related psychosocial issues has also declined among urologists treating male infertility. Despite the change in popularity of the procedure, though, TDI remains an appropriate therapeutic option for certain cases of male infertility, particularly in patients who have failed multiple cycles of in vitro fertilization/intracytoplasmic sperm injection or in men with no available sperm even after attempted microdissection testicular sperm extraction. Further consideration and research should be focused on the potential uses and indications for TDI.

Ovulatory status and follicular response predict success of clomiphene citrate-intrauterine insemination

OBJECTIVE

To test the hypothesis that anovulatory women would have good pregnancy rates (PRs), regardless of single or multiple follicular development, in response to clomiphene citrate (CC), whereas ovulatory women would have good PRs only when achieving multifollicular responses to CC.

DESIGN

Retrospective chart review.

SETTING

University-based infertility center.

PATIENT(S)

Two hundred and fifty-four women underwent 585 CC-IUI treatment cycles over a 3-year period.

INTERVENTION

Treatment with CC-IUI.

MAIN OUTCOME MEASURE(S)

Various factors were examined as predictors of clinical pregnancy rate (CPR) and live-birth rate (LBR) per cycle with the use of logistic regression.

RESULT(S)

Overall, the CPR was 11.1%, and the LBR was 8.7%. Of 65 clinical pregnancies, 81.5% resulted in live births (singletons, 67.7%; twins, 13.8%). There were no higher-order deliveries. In anovulatory women, the CPR and LBR were 15.7% and 13.6%, respectively. In ovulatory women, the CPR and LBR were 8.8% and 6.3%, respectively. As the number of large follicles increased from one to two, the LBR increased from 6.8% to 10.5%. Regarding the interaction of follicles with ovulatory status, anovulatory women had nearly double the CPR and LBR compared to those in ovulatory women, irrespective of the number of large follicles.

CONCLUSION(S)

Treatment with CC-IUI is more successful in anovulatory women than in ovulatory women. The multiple follicular response in both ovulatory and anovulatory women increases PRs.

Clomiphene citrate monitoring for intrauterine insemination timing: a randomized trial

OBJECTIVE

To compare pregnancy rates with two different methods of intrauterine insemination (IUI) timing in patients treated with clomiphene citrate (CC).

DESIGN

Prospective, randomized trial.

SETTING

Academic medical center.

PATIENT(S)

One hundred fifty ovulatory, infertile women.

INTERVENTION(S)

Patients were randomized into a luteinizing hormone (LH) surge group or a follicle monitoring/human chorionic gonadotropin (hCG) group. All patients underwent baseline ultrasound, and took clomiphene citrate, during days 5-9. Patients in the LH surge group underwent IUI on the day after a home test for the LH surge was positive, whereas those in the hCG group received hCG according to ultrasound parameters and underwent insemination 33-40 hours later. Patients remained in the same study group for up to three cycles.

MAIN OUTCOME MEASURE(S)

Pregnancy rates per cycle and per patient.

RESULT(S)

No significant differences were found between groups in pregnancy rates per patient or per cycle. The LH surge group underwent IUI significantly later than the hCG group. Cancellation rates were significantly higher for the LH surge group (31% vs. 11%) and attributable mainly to failure to detect an LH surge. The majority of pregnancies in both treatment groups occurred in the first cycle.

CONCLUSION(S)

The decision to use hCG for IUI timing should be influenced by factors other than pregnancy rates.

Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin

OBJECTIVE

To investigate factors that may affect pregnancy outcome following ovarian stimulation with clomiphene citrate (CC) combined with intrauterine insemination (IUI).

DESIGN

Retrospective cohort study.

SETTING

University teaching hospital.

PATIENT(S)

Three hundred and twenty women who underwent 691 ovarian stimulation cycles with CC for IUI.

INTERVENTION(S)

Ovarian stimulation with CC followed by a single IUI either 24 hours after a spontaneous serum LH surge (>25 mIU/mL) or 36 hours after intramuscular human chorionic gonadotropin (hCG) administration (10,000 IU) when the largest follicle had reached a diameter of 17 mm.

MAIN OUTCOME MEASURE(S)

Clinical pregnancies.

RESULT(S)

Women with ovulatory dysfunction who received hCG had significantly higher pregnancy rates (24.6%) compared with women with other types of infertility. There were no differences in pregnancy rates between the LH surge group and the hCG group (14.3% vs 12.4%). A spontaneous LH surge was noted in a variety of follicular sizes (14 to 35 mm). There was no correlation for age, body mass index, follicular diameter, number of mature follicles, other sperm characteristics, and pregnancy outcome in either group.

CONCLUSION(S)

After ovarian stimulation with CC, IUI is equally effective 24 hours after a spontaneous LH surge or 36 hours after administration of hCG. Spontaneous LH surges were observed at a variety of follicular sizes with comparable pregnancy rates. In women with ovulatory dysfunction, hCG administration before insemination may be beneficial.

Female age in ART: when to stop?

With increasing age the probability of ongoing pregnancy established by the use of assisted reproduction technology (ART) decreases. As a result the question arises whether age limits for the application of ART should be established. From a literature review and ongoing research data it appears that the costs per child born greatly increase after the age of 40 for both intrauterine insemination with mild ovarian stimulation and in vitro fertilisation treatment, while in cases of 44 and over, prognosis is flat zero. The willingness to pay for extra costs will greatly determine whether and at what age strict limits should be applied. Fortunately, predictive factors for success, like the antral follicle count, may enable the identification of women over 40 and under 44 that still have favourable prospects, thereby decreasing the necessary costs per childbirth and allowing couples into ART programs that are often denied based solely on female age.

Comparison of the effectiveness of single intrauterine insemination (IUI) versus double IUI per cycle in infertile patients

OBJECTIVE

To compare a single periovulatory intrauterine insemination (IUI) with a regimen based on double IUI, performed during preovulatory and periovulatory periods, in patients undergoing controlled ovarian hyperstimulation (COH).

DESIGN

Prospective, randomized study.

SETTING

Infertility and endocrinology units of a medical university.

PATIENT(S)

One hundred ten patients with male factor, cervical factor, and unexplained infertility who were undergoing 486 cycles of COH with IUI.

INTERVENTION(S)

The patients were randomly divided into two groups. One group underwent single IUI in the first cycle and double IUI in the second cycle; this alternating pattern was continued up to six cycles unless pregnancy occurred. For patients in the second group, double IUI was performed in the first cycle and single IUI in the second cycle; this pattern was repeated as in the first group.

MAIN OUTCOME MEASURE(S)

Relationship of single and double IUI to rates of clinical pregnancy and abortion.

RESULT(S)

Forty-two women became pregnant, with an overall pregnancy rate per cycle of 8.6% and pregnancy rate per couple of 38.2%. Pregnancy rate per cycle was 7.9% in single IUI cycles and was 9.4% in double IUI cycles; these findings were not statistically significant.

CONCLUSION(S)

Among patients undergoing COH-IUI, results of single and double IUI do not statistically differ.

Subfertility: causes, treatment and outcome

Common causes of subfertility include ovulatory disorders, tubal disease, peritoneal adhesions, endometriosis, uterine abnormalities, abnormalities of sperm and advancing female age. Infertility is unexplained after thorough evaluation in about 5-10% of cases. Significant caveats must be attached to the interpretation of available data regarding infertility treatments. Successful ovulation induction in anovulatory women is possible for nearly all women except in cases of ovarian failure. Surgery is an option for some patients with tubal damage, adhesions, endometriosis and uterine abnormalities. Male factor infertility may be amenable to treatment of a specific cause, but is often empirical with the use of intra-uterine insemination (IUI) or in vitro fertilization (IVF). Egg donation is currently the most effective treatment available for age-related infertility when other treatments have not been successful. Couples with unexplained infertility may be effectively treated with ovulation induction plus IUI or IVF.

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

OBJECTIVE

To determine how diagnosis, age, sperm quality, and number of preovulatory follicles affect pregnancy rates when multiple cycles of clomiphene citrate (CC)-IUI are performed.

DESIGN

Fifteen-year prospective observational study.

SETTING

Private infertility clinic.

PATIENT(S)

Three thousand, three hundred eighty-one cycles of husband or donor IUI.

INTERVENTION(S)

Ovulation induction with CC and IUI.

MAIN OUTCOME MEASURE(S)

Per-cycle pregnancy rate (PR), cumulative pregnancy rate (CPR).

RESULT(S)

Pregnancy rates remained constant through four cycles, then fell significantly for diagnoses other than ovulatory dysfunction. Mean PRs for cycles 1-4 were significantly lower for patients with the following characteristics: age >/=43 years, poor semen quality, single preovulatory follicles, and diagnoses other than ovulatory dysfunction. Additional cycles of CC-IUI compensated for low PRs because of age, semen quality, or number of follicles. After four cycles, CPRs were 46% for ovulatory dysfunction; 38% for cervical factor, male factor, and unexplained infertility; 34% for endometriosis; and 26% for tubal factor. After six cycles, CPRs were 65% for ovulation dysfunction, 35% for endometriosis, and unchanged for other diagnoses.

CONCLUSION(S)

Clomiphene citrate-intrauterine insemination should be performed for a minimum of four cycles. Additional cycles of CC-IUI can compensate for low pregnancy rates due to age, semen quality, or follicle number in patients with ovulation dysfunction.

Fertility treatment in the forty and older woman

PURPOSE

To determine the outcomes and logical progression of fertility treatment in women forty years and older using their own oocytes.

METHODS

This was a retrospective study in which 401 completed treatment cycles in 152 women aged forty and older were reviewed.

RESULTS

Assisted reproductive technology (ART) cycles (n = 58) were reviewed, comprising both in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). Intrauterine insemination (IUI) cycles (n = 343) were reviewed, consisting of 38 unstimulated natural cycle-IUI (NC-IUI), 194 clomiphene citrate-IUI (CC-IUI), and 111 injectable gonadotropins-IUI (INJ-IUI) cycles. The live birth rate of 15.5% for ART cycles was significantly higher than the live birth rate of 3.2% seen for all IUI cycles (p = 0.0007). There were no differences among treatment groups in spontaneous abortion, preterm delivery, or ectopic pregnancy rates.

CONCLUSIONS

For women > or = 40 years of age who wish to use their own eggs, ART offers the best chances for conception and delivery.

The Chinese experience of male infertility

The purpose of this study was to describe the lived experiences of Chinese men who were diagnosed as infertile. Thirty men who had experienced infertility were interviewed in or near the clinic of a large general teaching hospital located in Taiwan. The interviews were analyzed using content analysis. Five categories were generated from the interview data: emotional response after hearing the diagnosis; seeking possible explanations for the diagnosis; using alternative treatments other than those of Western medicine; stressfrom the discovery of the infertility secret by family, relatives, and friends; and grief for discontinuation of the family heritage. Men in this study described infertility as a frustrating and stressful experience. Findings from this study can add to the knowledge base on infertility and contribute to recommendations for improving the ways that health professionals guide, counsel, and support men who are infertile.

Superovulation and intrauterine insemination in cases of treated mild pelvic disease

PURPOSE

Our purpose was to examine the effect of treated mild pelvic disease on the outcome of superovulation with intrauterine insemination (SO/IUI).

METHODS

Three hundred cycles of SO/IUI were retrospectively reviewed for 118 women with laparoscopically treated minimal/mild endometriosis and 67 cycles for 28 women with minimal/mild distal tubal disease/adnexal adhesions and compared with 265 cycles in 111 couples with idiopathic infertility.

RESULTS

The monthly fecundity rate (MFR) of 6.8% and live birth rate (LBR) of 6% in the endometriosis group were significantly lower (P = 0.002) than those in the idiopathic infertility group (MFR = 13.5%, LBR = 12.1%). The 10.9% MFR and 7.5% LBR in the minimal/mild tubal/adnexal disease were not significantly different from those in the other two groups.

CONCLUSIONS

MFR and LBR were higher after SO/IUI in idiopathic infertility compared to those for treated mild/minimal endometriosis or mild/minimal tubal/adnexal adhesions. However, SO/IUI still remains a reasonable option for both these groups prior to IVF-ET.

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

OBJECTIVE

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

DESIGN

Observational prospective study.

SETTING

In vitro fertilization embryo transfer center.

PATIENT(S)

Five hundred ninety-four couples with unexplained infertility.

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

Cycle fecundity.

RESULT(S)

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

CONCLUSION(S)

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

Evaluation of pregnancy rates after intrauterine insemination according to indication, age, and sperm parameters

PURPOSE

Our purpose was to evaluate intrauterine insemination results obtained in our clinic and identify prognostic factors for the chance of pregnancy.

METHODS

A retrospective study of data from 1989 to 1996 was undertaken. Only first attempts were included in this study, except for the part on the cumulative pregnancy rates. Couples with either one-sided tubapathology, hormonal dysfunction, idiopathic infertility, or andrological indication were selected. All women were stimulated with clomiphene citrate. Five hundred sixty-six couples who underwent 1763 cycles were included in the study.

RESULTS

The overall pregnancy rate for first pregnancies was 6.9% per cycle and 21.4% per patient. For first intrauterine insemination attempts this was 8.8% per cycle/patient, varying between 5.0% for andrological indication and 10.6% for tubapathology, 10.0% for idiopatic indication, and 10.3% for hormonal indication. These differences were not significant. Age did not have a significant effect either, although there were no pregnancies observed in women 40 years or older. The number of inseminated spermatozoa significantly affected the pregnancy rate: < 2 million, 4.6%; > or = 2 to < 10 million, 3.9%; and > or = 10 million, 11.3%.

CONCLUSIONS

Unless semen characteristics are insufficient, intrauterine insemination is a useful treatment for infertile couples.

Basal estradiol and follicle-stimulating hormone predict fecundity in women of advanced reproductive age undergoing ovulation induction therapy

OBJECTIVE

To determine the prognostic value of single basal E2 and FSH levels as predictors of fecundity in women of advanced reproductive age who are undergoing ovulation induction with IUI therapy.

DESIGN

Prospective, observational.

SETTING

Fertility service of university medical center.

PATIENT(S)

Infertile couples in which the female partner was > or = 38 years old.

INTERVENTION(S)

Single assessment of basal E2 and FSH levels and ovulation induction with IUI.

MAIN OUTCOME MEASURE(S)

Cumulative and clinical pregnancy rates and live birth rates.

RESULT(S)

All live births occurred in patients with a basal E2 < or = 80 pg/mL (conversion factor to SI unit, 3.671), a basal FSH < or = 13 mIU/mL (conversion factor to SI unit, 1.00), and a chronological age < or = 42 years. In women 38 to 42 years of age, 10.3% had elevated basal E2 (> 80 pg/mL) in combination with normal basal FSH (< or = 13 mIU/mL), and no live births occurred in these couples. The cumulative live birth rate after four treatment cycles in women 38 to 42 years of age with both normal basal E2 (< or = 80 pg/mL) and FSH levels (< or = 13 mIU/mL) was 43.9%.

CONCLUSION(S)

Basal E2 improves the ability to predict fertility potential compared with basal FSH and chronological age alone. Basal E2, in combination with basal FSH and chronological age, has useful prognostic value in prospectively counseling patients of advanced reproductive age who are considering ovulation induction and IUI therapy.

Clomiphene citrate ovulation induction in combination with a timed intrauterine insemination: the value of urinary luteinizing hormone versus human chorionic gonadotropin timing

OBJECTIVE

To evaluate the clinical pregnancy rates (PRs) in anovulatory, male factor, and unexplained infertility using clomiphene citrate (CC) with an IUI and to evaluate the difference in PRs between urinary LH testing and hCG administration for timing of the IUI.

DESIGN

Retrospective clinical study.

SETTING

Academic, tertiary care fertility center.

PATIENT(S)

One hundred thirty-eight couples (432 cycles) undergoing IUI with CC ovulation induction as a treatment for unexplained, anovulatory, or male factor infertility were selected.

INTERVENTION(S)

All women with unexplained or male factor infertility received CC at a dose of 50 mg/d, and those with anovulation received CC at a dose ranging from 50 to 200 mg/d. All women in the study received a single IUI either the morning after a urinary LH surge or 36 to 38 hours after an evening hCG injection.

MAIN OUTCOME MEASURE(S)

Clinical PR.

RESULT(S)

There were no differences in the clinical PRs between LH testing or hCG administration in any of the three groups. Clinical PRs were extremely low in the male factor infertility group regardless of the timing used.

CONCLUSION(S)

These data suggest that the success of IUI with CC is not dependent on the method used to establish the timing for the IUI. In couples undergoing IUI with CC, the use of urinary LH testing may result in lower costs by reducing patient visits and the midcycle ultrasound.