The performance of primary and secondary unexplained infertility in an in vitro fertilization-embryo transfer program

Effects of artificial cycles with and without gonadotropin-releasing hormone agonist pretreatment on frozen embryo transfer outcomes in patients with adenomyosis

Gonadotropin-releasing hormone agonist (GnRH-a) is generally added to the improve pregnancy outcomes of hormone replacement therapy cycles among patients with adenomyosis. We aimed to investigate whether adding GnRH-a can result in better pregnancy outcomes. This retrospective analysis included 341 patients with adenomyosis who underwent frozen embryo transfer (FET) after in vitro fertilization (IVF). The control group was treated only with hormone replacement therapy cycles to prepare the endometrium, and GnRH-a was added to the study group before hormone administration to adjust the menstruation cycle. Based on the similar baseline values and embryological data, there was no significant difference in the clinical pregnancy rates (40.63% vs. 42.54%, P = 0.72) and live birth rates (23.75% vs. 23.75%, P = 0.74) of the control and study groups. Other secondary outcomes, including the rates of clinical miscarriage, ectopic pregnancy, preterm birth and term birth, were not significantly different between the two groups. Compared with the hormone replacement therapy cycle alone, GnRH-a downregulation based on a hormone replacement therapy cycle may not increase the rate of clinical pregnancy or live birth of IVF-ET with FET among infertile patients with adenomyosis.

Associations of sperm DNA fragmentation with lifestyle factors and semen parameters of Saudi men and its impact on ICSI outcome

BACKGROUND

Male factor infertility is quite common as 30-50% of infertility cases are due to sperm defects. The high sperm DNA fragmentation is one of the causes of male factor infertility. Many factors cause sperm DNA fragmentation and could be testicular or post-testicular. The purpose of this study was to assess relationships among sperm DNA fragmentation, lifestyle factors and semen values of Saudi men and to determine impact of sperm DNA fragmentation on ICSI cycle outcome.

METHODS

The duration of this study was from January 2015 to June 2016. The cases with female factor infertility were excluded. In total 94 couples were selected for investigation. The study parameters were male age, body mass index, smoking, semen values, % sperm DNA fragmentation, fertilization rate and pregnancy outcome. The ICSI procedure was performed in all patients per standard protocol. The semen samples were grouped based on % sperm DNA fragmentation into < 15%, 15-30 and > 30% which corresponded to low, moderate and high sperm DNA fragmentation, respectively.

RESULTS

There was no difference in ICSI outcome in low and moderate sperm DNA fragmentation, however, in high sperm DNA fragmentation no patient achieved pregnancy. In this study, 53.19% Saudi men had low, 32.98% moderate and 13.83% high DFI. Semen volume, sperm morphology and fertilization rate did not show any correlation trend with DNA fragmentation, however, sperm concentration and motility were negatively correlated in all DFI categories. The BMI was positively correlated in moderate DFI category and smoking was positively correlated with low DFI category. The age was positively correlated in moderate and high DFI categories.

CONCLUSIONS

The results of this study indicated that 14% Saudi men had high DNA fragmentation. The BMI was positively correlated in moderate DFI category and smoking was positively correlated with low DFI category. The age was positively correlated in moderate and high DFI categories.

Present concept of unexplained infertility

Despite improvements in both diagnostic assessment and treatment of infertile couples, many couples still have no explanation for their infertility. Unexplained infertility (the failure to conceive of a couple in whom no definitive cause for infertility can be found) has an incidence of 10-20% in all infertile couples. The incidence varies with the population studied and with the criteria used. Unexplained infertility is not an absolute condition but rather a relative inability to conceive, and many of these couples may conceive without treatment. The treatment options for unexplained infertility are several and the treatment results are promising. Expectant management can be recommended if the woman is under 28-30 years of age and the infertility duration is less than 2-3 years. In vitro fertilization (IVF) has revolutionized the treatment of infertile couples, as well as profoundly increasing the basic understanding of human reproduction. IVF can be used as both a diagnostic and a therapeutic tool in couples with unexplained infertility. The pregnancy rates with IVF are good, at 40% per treatment cycle. In addition, the outcome of pregnancies among women with unexplained infertility is generally comparable to that of spontaneous and other pregnancies using assisted reproductive technologies.

Spontaneous conception after a successful attempt at in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To determine the incidence of spontaneous pregnancy in women who were not actively undergoing therapy after a successful attempt at IVF/intracytoplasmic sperm injection and to characterize its pattern of occurrence.

DESIGN

Retrospective postal questionnaire.

SETTING

An assisted reproduction unit at a university-based teaching hospital.

PATIENT(S)

Five hundred thirteen replies were received from 530 questionnaires mailed.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Spontaneous pregnancy. Women who did and did not conceive spontaneously after successful IVF treatment were compared in terms of their age, duration of infertility, previous reproductive history, and indication for treatment at the time of assisted reproduction.

RESULT(S)

The rate of spontaneous conception among the survey respondents was 20.7%. Younger women (</=34 years of age) had a higher rate of spontaneous conception, as did those with a shorter duration of infertility. Women with unexplained infertility and endometriosis also were more likely to conceive. Few of those who had undergone intracytoplasmic sperm injection conceived, whereas 21.6% of those whose partners had had sperm quality sufficient for IVF later conceived spontaneously.

CONCLUSION(S)

The chances of spontaneous conception after successful ART therapy are significant in some groups of patients. This has implications for the practice of assisted reproduction and the obstetric care of patients who conceive with treatment. Contraceptive advice may need to be provided to couples who undergo IVF/intracytoplasmic sperm injection.

Efficacy of treatment for unexplained infertility

OBJECTIVE

To analyze the efficacy and cost-effectiveness of alternative treatments for unexplained infertility.

DESIGN

Retrospective analysis of 45 published reports.

SETTING

Clinical practices.

PATIENT(S)

Couples who met criteria for unexplained infertility. Women with Stage I or Stage II endometriosis were included.

INTERVENTION(S)

Observation; clomiphene citrate (CC); gonadotropins (hMG); IUI; and GIFT and IVF.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate.

RESULT(S)

Combined pregnancy rates per initiated cycle, adjusted for study quality, were as follows: no treatment = 1.3%-4.1%; IUI = 3.8%; CC = 5.6%; CC + IUI = 8.3%; hMG = 7.7%; hMG + IUI = 17.1%; IVF = 20.7%; GIFT = 27.0%. The estimated cost per pregnancy was $10,000 for CC + IUI, $17,000 for hMG + IUI, and $50,000 for IVF.

CONCLUSION(S)

Clomiphene citrate + IUI is a cost-effective treatment for unexplained infertility. If this treatment fails, hMG + IUI and assisted reproduction are efficacious therapeutic options.

Advanced methods for evaluation of sperm quality

Routine semen analysis includes measurements of sperm concentration, motility, and morphology. In our study, three additional tests were evaluated in relation to fertilization rate in an in vitro fertilization program: the freezing and hypo-osmotic swelling tests that evaluate the functional integrity and stability of the sperm membrane under extreme osmotic conditions, and migration sedimentation test that isolates high-quality motile sperm cells. The study was performed on semen delivered by men of couples treated at the In Vitro Fertilization Unit, and men who served as semen donors (fresh or cryopreserved semen). No correlation was found between the sperm fertilization rate, and the decrease in motility percent following the freezing-thawing process. Thus, the freezing test cannot be used to predict semen fertilization capacity. The hypo-osmotic swelling test was applied on semen given by a similar population of men. While the hypo-osmotic swelling test values carried out with fresh semen was found to have good correlation with fertilization, no correlation was found when frozen thawed semen was used. Post-migration sedimentation test sperm characteristics, and especially the recovery rate of the motile sperm, were significantly better in in vitro fertilization cycles with fertilizations. Both the hypo-osmotic swelling test and migration sedimentation test can assist in evaluating semen quality, judged by the fertilization rate in an in vitro fertilization program.

Outcome of donor versus husband insemination in couples with unexplained infertility treated by in vitro fertilization and embryo transfer

OBJECTIVE

To examine the IVF-ET outcome of couples with unexplained infertility treated by husband versus donor sperm.

DESIGN

A retrospective analysis of the IVF-ET outcome of couples with unexplained infertility treated by either husband or donor sperm and in a subgroup of patients treated simultaneously by husband and donor sperm.

SETTING

IVF Unit, Serlin Maternity Hospital, Tel Aviv, Israel.

PATIENTS

Couples diagnosed as having unexplained infertility underwent IVF at our Unit; included were 96 couples treated by husband insemination (group A), 27 couples who received donor insemination because of azoospermia (group B), and 8 couples who sought donor insemination after having previously failed IVF (group C).

RESULTS

No statistically significant difference was found between groups A and B regarding age of the females, duration of infertility, number of IVF cycles, fertilization rate, number of ETs, and pregnancy rate. Oocytes collected in group C were subdivided further into two groups: 45 were incubated with husband sperm and 46 were incubated with donor sperm. Fertilization rates were 46.6% and 50%, respectively. One pregnancy occurred.

CONCLUSION

In couples with unexplained infertility who had undergone IVF-ET with husband insemination, the fertilization and pregnancy rates were similar to those of couples who were treated by donor sperm.

Fertilization failure and dysfunctions as possible causes for human idiopathic infertility

Consideration of the most common currently practiced laboratory assays for human spermatozoal fertility are discussed, with reference to the relevance of such assays to success or failure in human in vitro fertilization (IVF). Such IVF therapy should be the definitive challenge for human spermatozoal fertilization ability. However, when fertilization fails, is polyspermic, or is suboptimal, then questions concerning the step or steps in the process of fertilization which are dysfunctional remain unanswered. Quite possibly new assays need to be devised to address these problems, while in the meantime our present laboratory assay systems need to be improved to discern those defects in fertilization which operate in many cases of human idiopathic infertility.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

The potential diagnostic use of human zona-free eggs prepared from oocytes that failed to fertilize in vitro

Human oocytes that failed to fertilize in a clinical in vitro fertilization (IVF) program were freed from the zona pellucida and reinseminated with spermatozoa from subfertile patients or from fertile donors. Penetration results were, in general, significantly worse when patients spermatozoa were used as compared with donor spermatozoa. When inseminated with donor spermatozoa, oocytes from cases of male infertility gave better penetration results as compared with those from cases of idiopathic infertility with no apparent sperm defect. No differences in penetration results were found between oocytes aged 1 day and 2 days in culture before zona removal and reinsemination, even though less pronuclei reached full functional maturity in the more aged group of eggs. These results indicate that human zona-free eggs prepared from oocytes after unsuccessful IVF attempts may be used to assess the fertilizing ability of human spermatozoa. Moreover, when used with donor spermatozoa, this system may help to determine the contribution of the oocyte to fertilization failure.