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Lensen S, Sydes MR, Polyakov A, Wilkinson J. When to randomize patients in a randomized controlled trial? Fertil Steril 2024; 121:902-904. [PMID: 38494103 DOI: 10.1016/j.fertnstert.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
The timing of randomization should be considered carefully in the context of each trial because it has implications for the particular research question answered. In most instances, randomization should be delayed until as close as practically possible to the moment of intervention. In some cases, early randomization may offer certain advantages, but trialists should balance these, including any administrative complexity or inconvenience, against the risk of avoidable protocol violations and avoidable drop out.
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Affiliation(s)
- Sarah Lensen
- Department of Obstetrics, Gynaecology and Newborn Health, Royal Women's Hospital, University of Melbourne, Melbourne, Victoria, Australia.
| | - Matthew R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Alex Polyakov
- Department of Obstetrics, Gynaecology and Newborn Health, Royal Women's Hospital, University of Melbourne, Melbourne, Victoria, Australia; Reproductive Biology Unit, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Jack Wilkinson
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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2
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Massarotti C, Fraire-Zamora JJ, Liperis G, Uraji J, Sharma K, Serdarogullari M, Ammar OF, Makieva S, Ali ZE, Romualdi D, Somigliana E, Sakkas D, Dancet E, Mincheva M. Understanding and addressing unexplained infertility: from diagnosis to treatment. Hum Reprod 2024; 39:1155-1159. [PMID: 38531672 DOI: 10.1093/humrep/deae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/25/2024] [Indexed: 03/28/2024] Open
Affiliation(s)
- Claudia Massarotti
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- DINOGMI Department, University of Genova, Genova, Italy
| | | | - George Liperis
- Westmead Fertility Centre, Institute of Reproductive Medicine, University of Sydney, Westmead, NSW, Australia
- Embryorigin Fertility Centre, Larnaca, Cyprus
| | - Julia Uraji
- MVZ Kinderwunsch am Seestern, Düsseldorf, Germany
| | - Kashish Sharma
- HealthPlus Fertility Center, HealthPlus Network of Specialty Centers, Abu Dhabi, United Arab Emirates
| | - Munevver Serdarogullari
- Department of Histology and Embryology, Faculty of Medicine Cyprus International University, Northern Cyprus, Turkey
| | - Omar F Ammar
- Ar-Razzi Private Hospital, IVF Centre, Ramadi, Iraq
- Department of Obstetrics and Gynaecology, College of Medicine, University of Anbar, Ramadi, Iraq
| | - Sofia Makieva
- Kinderwunschzentrum, Klinik für Reproduktions-Endokrinologie, Universitätsspital Zürich, Zurich, Switzerland
| | - Zoya E Ali
- Research & Development Department, Hertility Health Limited, London, UK
| | - Daniela Romualdi
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Edgardo Somigliana
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | | | - Eline Dancet
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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3
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Au LS, Feng Q, Shingshetty L, Maheshwari A, Mol BW. Evaluating prognosis in unexplained infertility. Fertil Steril 2024; 121:717-729. [PMID: 38423380 DOI: 10.1016/j.fertnstert.2024.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
IMPORTANCE The diagnosis of unexplained infertility presents a dilemma as it signifies both uncertainty about the cause of infertility and the potential for natural conception. Immediate treatment of all would result in overtreatment. Prediction models estimating the likelihood of natural conception and subsequent live birth can guide treatment decisions. OBJECTIVE To evaluate if in couples with unexplained infertility, prediction models are effective in guiding treatment decisions. EVIDENCE REVIEW This review examines 25 studies that assess prediction models for natural conception in couples with unexplained infertility in terms of derivation, validation, and impact analysis. FINDINGS The largest prediction models have been integrated in the synthesis models of Hunault, which includes female age and infertility duration, having been pregnant before and motile sperm percentage. Despite its limited discriminative capacity, this model demonstrates excellent calibration. Importantly, the impact of the Hunault model has been evaluated in randomized clinical trials, and shows that in couples with unexplained infertility and 12-month natural conception chances exceeding 30%, immediate treatment with intrauterine insemination (IUI) and controlled ovarian hyperstimulation is not better than expectant management for 6 months. Below the threshold of 30%, treatment with IUI is superior over expectant management, but immediate in vitro fertilization was not better than IUI. CONCLUSION In couples with unexplained infertility and a good prognosis for natural conception, treatment can be delayed, whereas in couples with a poor prognosis, immediate treatment (with IUI-controlled ovarian hyperstimulation) is warranted. RELEVANCE These data indicate that in couples with unexplained infertility, integration of prediction models into clinical decision making can optimize treatment selection and maximize fertility outcomes while limiting unnecessary treatment.
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Affiliation(s)
- Ling Shan Au
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Qian Feng
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Laxmi Shingshetty
- Aberdeen Centre of Reproductive Medicine, NHS Grampian, Aberdeen, United Kingdom
| | - Abha Maheshwari
- Aberdeen Centre of Reproductive Medicine, NHS Grampian, Aberdeen, United Kingdom
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash Health, Melbourne, Victoria, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom.
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Zhang D, Cai H, Xie J, Chen L, Zhang Z, Shi J. Cumulative live birth rates following intrauterine insemination using donor and husband sperm in different age groups: A cohort study of 10 415 insemination cycles. Int J Gynaecol Obstet 2024. [PMID: 38623946 DOI: 10.1002/ijgo.15539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES To assess the age-specific cumulative live birth rates (CLBRs) in intrauterine insemination (IUI) cycles using either donor or husband sperm, and to investigate the impact of sperm sources on IUI success among women within the same age group. METHODS This retrospective cohort study comprised women who underwent IUI with donor sperm (IUI-D) or husband sperm (IUI-H) from 2017 to 2021. The women were stratified based on their age at the initiation of insemination into four categories: <35, 35-37, 38-39 and ≥40 years. RESULTS A total of 5253 women undergoing 10 415 insemination cycles (3354 with IUI-D and 7061 with IUI-H) were included. The CLBRs decreased significantly with increasing maternal age within donor and husband insemination groups (P < 0.001). In the IUI-D group, the crude CLBRs were 61.50% in women aged <35, 48.91% in 35-37, 24.14% in 38-39 and 11.76% in the ≥40-year age category, respectively. The corresponding rates in the IUI-H group were 27.62%, 22.96%, 13.73% and 6.90%, respectively. Within the <35 and 35-37-year age categories, the CLBRs were significantly higher following IUI-D cycles compared to IUI-H cycles, with hazard ratios (HR) of 1.85 (1.68-2.04) and 1.69 (1.16-2.47), respectively. However, within the 38-39 and ≥40-year age categories, both IUI-D and IUI-H resulted in comparable low CLBRs, with HRs of 1.91 (0.77-4.76) and 1.80 (0.33-9.86), respectively. CONCLUSION Advanced maternal age affects the whole process of fertility. Therefore, it could be reasonable to limit the number of IUI performed in women aged 40 years and older, even in couple using donor sperm for reproduction.
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Affiliation(s)
- Dian Zhang
- Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China
- Graduate Department, Xi'an Medical University, Xi'an, China
| | - He Cai
- Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China
| | - Jinlin Xie
- Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China
| | - Lijuan Chen
- Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China
| | - Zhou Zhang
- Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China
| | - Juanzi Shi
- Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China
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Huang C, Shi Q, Xing J, Yan Y, Shen X, Shan H, Sun H, Mei J. The relationship between duration of infertility and clinical outcomes of intrauterine insemination for younger women: a retrospective clinical study. BMC Pregnancy Childbirth 2024; 24:199. [PMID: 38486148 PMCID: PMC10938817 DOI: 10.1186/s12884-024-06398-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The objective of this research was to elucidate the association between the length of infertility and the outcomes of intrauterine insemination (IUI) in women of varying ages - a topic that has been the subject of investigation for numerous years, yet lacks a definitive consensus. METHODS A retrospective cohort investigation involving 5268 IUI cycles was undertaken at the Reproductive Medicine Center of Nanjing Drum Tower Hospital from 2016 to 2022. Utilizing the smooth fitting curve along with threshold and saturation effect analysis, the correlation between infertility duration and IUI clinical pregnancy rates was discerned. Moreover, patients were bifurcated into two cohorts based on their respective infertility durations. A secondary examination was also performed employing propensity-score matching to mitigate the impact of confounding variables. Subsequent threshold and saturation effect analysis was carried out across various subgroups, segmented on the basis of age differentiation. RESULTS When the duration of infertility was more than 5 years, the clinical pregnancy rate decreased with the increase of infertility duration (aOR: 0.894, 95%CI: 0.817-0.991, p = 0.043). The multivariate regression analysis suggested that longer duration of infertility (≥ 5 years) was significantly correlated with the lower clinical pregnancy rate (aOR: 0.782, 95% CI: 0.643-0.950, p = 0.01). After the propensity-score matching, the clinical pregnancy rate of women with longer infertility duration were also higher. When the duration of infertility was more than 5 years, the clinical pregnancy rate of women younger than 35 years old decreased with the increase of infertility duration (aOR: 0.906, 95%CI: 0.800-0.998, p = 0.043). CONCLUSIONS The clinical pregnancy rate and live birth rate of IUI in young women (< 35 years old) who have been infertile for more than 5 years significantly decrease with the prolongation of infertility time. Therefore, for young women who have been infertile for more than 5 years, IUI may not be the best choice.
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Affiliation(s)
- Chenyang Huang
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China
| | - Qingqing Shi
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China
| | - Jun Xing
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China
| | - Yuan Yan
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China
| | - Xiaoyue Shen
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China
| | - Huizhi Shan
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China
| | - Haixiang Sun
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China.
| | - Jie Mei
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, 210008, China.
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Alorf F, Alani S, Steiner N, Dahan MH. How successful is intrauterine insemination after failed IVF? A study of 551 women. Reprod Biomed Online 2024; 48:103684. [PMID: 38271821 DOI: 10.1016/j.rbmo.2023.103684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 01/27/2024]
Abstract
RESEARCH QUESTION What is the success rate of intrauterine insemination (IUI) after failing IVF? DESIGN This retrospective cohort study evaluated the pregnancy outcomes of 551 patients who underwent a total of 992 IUI cycles at an academic fertility centre between October 2008 and April 2018. RESULTS The study participants (n = 551) had previously failed one to three fresh IVF cycles and any resultant embryo transfers, and subsequently underwent a total of 992 IUI cycles. When comparing demographics, women with ongoing pregnancies, clinical pregnancies and positive pregnancies were significantly younger (P = 0.037, P = 0.025 and P = 0.049, respectively) compared with women who did not conceive. The cumulative ongoing pregnancy rate for all IUI cycles was 7.44% per patient (41 pregnancies in 551 patients), and the ongoing pregnancy rate after the first IUI cycle was 4.72%. In single women who had previously failed six IUI cycles before undergoing IVF cycles with donor sperm, the cumulative ongoing pregnancy rate was 15.8% in donor sperm IUI cycles compared with 5.1% in women who used their partner's sperm for both IVF and IUI cycles, with an adjusted odds ratio of 6.1. Patient age, number of previous pregnancies, daily gonadotrophin dose for IVF, number of mature follicles at trigger, and number of failed IVF cycles failed to predict pregnancy outcomes. CONCLUSION Ongoing pregnancy following IUI after failed IVF occurs at a rate of approximately 5% per cycle, and this rate is higher if donor sperm is used for both IVF and IUI cycles. This can be considered with proper counselling in women aged <40 years, and may be discouraged in women aged ≥43 years.
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Affiliation(s)
- Faisel Alorf
- Obstetrics and Gynecology Department, McGill University, Montreal, Quebec, Canada.
| | - Sanah Alani
- Obstetrics and Gynecology Department, McGill University, Montreal, Quebec, Canada
| | - Naama Steiner
- Obstetrics and Gynaecology Department, Soroka Medical Centre, Beersheba, Israel
| | - Michael H Dahan
- Division of Reproductive Endocrinology and Infertility, McGill University, Montreal, Quebec, Canada
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Taniguchi M, Kanasaki H, Oride A, Okada H, Imamura K, Kyo S. Impact of current and previous sperm findings on outcomes of intrauterine insemination. Reprod Med Biol 2024; 23:e12574. [PMID: 38590943 PMCID: PMC11000811 DOI: 10.1002/rmb2.12574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/01/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024] Open
Abstract
Purpose To examine the association between semen characteristics and outcomes of intrauterine insemination (IUI). Methods This retrospective analysis examined 1380 IUI procedures involving 421 couples. The association of clinical pregnancy with pre- and post-wash sperm characteristics was assessed. Results Pre- and post-wash sperm characteristics did not differ between IUI cycles that resulted in pregnancy and those that did not. When the motility of pre-wash sperm was below the normal range (<42%) established by the World Health Organization (WHO), the pregnancy rate was significantly lower. In the IUI cycles when post-wash sperm motility was below the WHO standard, pregnancy was not achieved. The frequency of improvement in post-wash sperm motility in repeated IUI cycles appeared to correlate with the success of future IUI cycles. At the fourth IUI cycle, pregnancy was not achieved unless the post-wash sperm motility was normal in at least two of three attempts. When post-wash sperm concentration was below the normal range, the woman's age did not affect the IUI outcomes. Conclusions Sperm motility above the lower limit of the WHO criteria in post-wash semen samples is an important factor in IUI outcomes.
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Affiliation(s)
- Maki Taniguchi
- Department of Obstetrics and GynecologyShimane University Faculty of MedicineIzumoJapan
| | - Haruhiko Kanasaki
- Department of Obstetrics and GynecologyShimane University Faculty of MedicineIzumoJapan
| | - Aki Oride
- Department of Obstetrics and GynecologyShimane University Faculty of MedicineIzumoJapan
| | - Hiroe Okada
- Department of Obstetrics and GynecologyShimane University Faculty of MedicineIzumoJapan
| | - Kayo Imamura
- Department of Obstetrics and GynecologyUnnan City HospitalUnnanJapan
| | - Satoru Kyo
- Department of Obstetrics and GynecologyShimane University Faculty of MedicineIzumoJapan
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Raperport C, Desai J, Qureshi D, Rustin E, Balaji A, Chronopoulou E, Homburg R, Khan KS, Bhide P. The definition of unexplained infertility: A systematic review. BJOG 2023. [PMID: 37957032 DOI: 10.1111/1471-0528.17697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/15/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice. OBJECTIVES This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis. SEARCH STRATEGY CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language. DATA COLLECTION AND ANALYSIS Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range. MAIN RESULTS Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies. CONCLUSIONS This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.
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Affiliation(s)
- Claudia Raperport
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Desai
- Queen Mary University of London Medical School, London, UK
| | | | | | - Aparna Balaji
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | | | - Roy Homburg
- Hewitt Fertility Centre, Liverpool Women's Hospital, Liverpool, UK
| | - Khalid Saeed Khan
- Department of Preventative Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
- CIBER Epidemiology and Public Health, Madrid, Spain
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Man JKY, Parker AE, Broughton S, Ikhlaq H, Das M. Should IUI replace IVF as first-line treatment for unexplained infertility? A literature review. BMC Womens Health 2023; 23:557. [PMID: 37891606 PMCID: PMC10612289 DOI: 10.1186/s12905-023-02717-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Unexplained infertility accounts for 25% of infertility causes in the UK. Active intervention methods, such as intrauterine insemination (IUI) or in vitro fertilisation (IVF), are often sought. Despite the National Institute for Health and Care Excellence (NICE) recommending IVF for unexplained infertility, this recommendation has generated an ongoing debate, with few fertility clinics discontinuing the use of IUI as the first-line management of choice. In contrast to NICE, recent guidance released from the European Society for Human Reproduction and Embryology (ESHRE) in August 2023 supports the use of IUI as first-line. High-quality evidence behind such interventions is lacking, with current literature providing conflicting results. AIMS This review aims to provide a literature overview exploring whether IUI or IVF should be used as first-line treatment for couples with unexplained infertility, in the context of current guidelines. METHODS The primary outcome used to assess efficacy of both treatment methods is live birth (LB) rates. Secondary outcomes used are clinical pregnancy (CP) and ongoing pregnancy (OP) rates. A comprehensive literature search of 4 databases: Ovid MEDLINE, EMBASE, Maternity & Infant Care and the Cochrane Library were searched in January 2022. Upon removal of duplications, abstract screening, and full-text screening, a total of 34 papers were selected. DISCUSSION/CONCLUSION This review highlights a large discrepancy in the literature when examining pregnancy outcomes of IUI and IVF treatments. Evidence shows IUI increases LB and CP rates 3-fold compared to expectant management. Literature comparing IUI to IVF is less certain. The review finds the literature implies IVF should be used for first-line management but the paucity of high-quality randomised controlled trials (RCTs), coupled with heterogeneity of the identified studies and a lack of research amongst women > 40 years warrants the need for further large RCTs. The decision to offer IUI with ovarian stimulation (IUI-OS) or IVF should be based upon patient prognostic factors. We suggest that IUI-OS could be offered as first-line treatment for unexplained infertility for women < 38 years, with good prognosis, and IVF could be offered first to those > 38 years. Patients should be appropriately counselled to enable informed decision making.
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Affiliation(s)
- Jessica Ka-Yan Man
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK.
| | - Anne Elizabeth Parker
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
| | - Sophie Broughton
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Hamza Ikhlaq
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
| | - Mausumi Das
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
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Rachmawati A, Krisnadi SR, Santoso SA, Nugrahani AD. Association between follicle size, endometrial thickness, and types of ovarian stimulation (Clomiphene citrate and Letrozole) with biochemical pregnancy rate in women undergone intrauterine insemination. BMC Res Notes 2023; 16:286. [PMID: 37875998 PMCID: PMC10598886 DOI: 10.1186/s13104-023-06529-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE There was also a lack of data regarding the effect of follicle size, endometrial thickness, and ovarian stimulation as predictors of intrauterine insemination (IUI) success rate in Indonesia, especially in the Aster Clinic and Bandung Fertility Centre. This study was performed to explore the relationship between follicle size, endometrial thickness, and types of ovarian stimulation (Clomiphene citrate/CC vs Letrozole) with biochemical pregnancy rate in women undergone IUI. We performed a case-control study in 122 women aged 20-40 years with unexplained infertility who had completed the IUI program for a maximum of three cycles. Data were extracted from medical records. Independent T-test and multivariate analyses were used to analyse the difference between variables using IBM SPSS 24.0. P-value < 0.05 was considered statistically significant. RESULT Follicle sizes of 18-22 mm in both Clomiphene citrate (CC) and Letrozole groups were shown to increase biochemical pregnancy rate (P = 0.001). There is no relationship between endometrial thickness and pregnancy rate. Biochemical pregnancy rate in women using Letrozole was 1.513 times higher than women using CC. The follicle size of 18-22 mm and using Letrozole rather than CC as ovarian stimulators are predictive factors associated with a higher pregnancy rate in women undergone IUI.
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Affiliation(s)
- Anita Rachmawati
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Padjadjaran - Dr. Hasan Sadikin General Hospital, Pasteur No. 38, Bandung, West Java, 40161, Indonesia
| | - Sofie Rifayani Krisnadi
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Padjadjaran - Dr. Hasan Sadikin General Hospital, Pasteur No. 38, Bandung, West Java, 40161, Indonesia
| | - Shasya Aniza Santoso
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Padjadjaran - Dr. Hasan Sadikin General Hospital, Pasteur No. 38, Bandung, West Java, 40161, Indonesia.
| | - Annisa Dewi Nugrahani
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Padjadjaran - Dr. Hasan Sadikin General Hospital, Pasteur No. 38, Bandung, West Java, 40161, Indonesia
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Wessel JA, Hunt S, van Wely M, Mol F, Wang R. Alternatives to in vitro fertilization. Fertil Steril 2023; 120:483-493. [PMID: 36642301 DOI: 10.1016/j.fertnstert.2023.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/07/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
There have been concerns on the potential overuse of in vitro fertilization (IVF) in view of the lack of evidence on effectiveness in certain populations, potential short and long-term safety risks, and economic considerations. On the other hand, the use of alternatives to IVF seems to be underappreciated in clinical practice as well as research. In this review, we summarized the up-to-date evidence on the effectiveness, safety as well as cost-effectiveness of different alternatives to IVF, including expectant management, intrauterine insemination, tubal flushing, in vitro maturation as well as intravaginal culture. We also discussed the trend of IVF use over the last decade and the available tiers of service because of intravaginal culture, and revisited the roles of different alternatives to IVF in modern reproductive medicine from both clinical and research perspectives.
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Affiliation(s)
- Jennifer A Wessel
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam, the Netherlands
| | - Sarah Hunt
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Madelon van Wely
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam, the Netherlands
| | - Femke Mol
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam, the Netherlands
| | - Rui Wang
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.
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Wang Q, Gu X, Chen Y, Yu M, Peng L, Zhong S, Wang X, Lv J. The effect of sperm DNA fragmentation on in vitro fertilization outcomes of unexplained infertility. Clinics (Sao Paulo) 2023; 78:100261. [PMID: 37515928 PMCID: PMC10407277 DOI: 10.1016/j.clinsp.2023.100261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Infertility is caused by heterogeneous risks, but most of them are unexplained. The sperm DNA Fragmentation Index (DFI) was increasingly acknowledged as a parameter for the evaluation of male infertility. This study aimed to investigate the association between sperm DFI and laboratory and clinical outcomes in a population with unexplained infertility. METHODS The clinical data of an infertile population was collected for the selection of reproductive patients with unexplained infertility. The authors classified the patients with normal sperm parameters in a control group (DFI < 25%) and an observation group (DFI ≥ 25%) and compared the difference in basal characteristics, laboratory, and clinical outcomes between the two groups. The authors conducted a correlation analysis to examine the relationship between DFI and the number of D3 good-quality embryos, as well as the clinical pregnancy rate and live birth rate. A total of 176 cases were enrolled in the retrospective study. RESULTS The observation group (n = 88) showed advanced male age, lower sperm concentration, progressive motility, and morphology assessment than the control group. In addition, lower No. of D3 good-quality embryos, clinical pregnancy rate, and the live birth rate were shown in the observation group. A negative correlation between the DFI and No. of D3 good-quality embryos (rs = -0.347, p < 0.001) or live birth rate (rs = -0.185, p = 0.028) was shown. CONCLUSIONS Sperm DFI was a good indicator for the prediction of D3 good-quality embryos in unexplained infertility couples, but it did not provide sufficient information regarding clinical pregnancy outcome but live pregnancy outcome.
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Affiliation(s)
- Qingxin Wang
- Dushu Lake Hospital Affiliated to Soochow University, Jiangsu, China
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Xiaoling Gu
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Yannan Chen
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Minyan Yu
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Lingna Peng
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Shuping Zhong
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Xia Wang
- Affiliated Hospital of Nantong University, Jiangsu, China
| | - Jinxing Lv
- Dushu Lake Hospital Affiliated to Soochow University, Jiangsu, China
- The First Affiliated Hospital of Soochow University, Jiangsu, China
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13
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Abstract
Infertility is a common condition which causes substantial patient distress and prompts patients to seek care in outpatient gynecologic offices. The evaluation and treatment of infertility can be costly and insurance coverage for these services varies widely. Obstetrician-gynecologists and other women's health care professionals often struggle with the approach for patients without insurance coverage for infertility care. This article reviews the status of insurance coverage for infertility services, reviews options for both the evaluation and management of infertility for patients who do not have infertility insurance coverage, and provides resources for ongoing advocacy and support for these patients.
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14
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Zhang K, Huang S, Xu H, Zhang J, Wang E, Li Y, Zhu C, Shu J. Effectiveness of gonadotrophin-releasing hormone agonist therapy to improve the outcomes of intrauterine insemination in patients suffering from stage I-II endometriosis. Ann Med 2022; 54:1330-1338. [PMID: 35535701 PMCID: PMC9126587 DOI: 10.1080/07853890.2022.2071458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/28/2022] [Accepted: 04/23/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore the role of postoperative gonadotrophin releasing hormone agonist (GnRH-a) therapy before treatment with intrauterine insemination (IUI) for infertile females with stage I-II endometriosis. MATERIAL AND METHODS Ninety-seven patients diagnosed with stage I-II endometriosis before IUI were enrolled in this study. The clinical pregnancy rate, cumulative pregnancy rate, live birth rate and newborn conditions were compared between the two groups with and without GnRH-a therapy. RESULTS The clinical pregnancy rate of IUI in the GnRH-a group was higher than that in the control group (15.29% vs. 11.82%, p = .035). By logistic regression analysis, patients treated with GnRH-a had a higher clinical pregnancy rate than those without (adjusted odds ratio (AOR) 23.190, 95% confidence interval (CI) 1.238-434.312). The live birth rate per IUI cycle in the GnRH-a group was also higher than in the controls (12.94% vs. 10%). However, the difference was not statistically significant (p = .311, AOR 4.844, 95% CI 0.229-102.320). The patients with GnRH-a therapy had a similar incidence of multiple pregnancy rate (0% vs. 0%), miscarriage rate (2.35% vs. 0.91%) and ectopic pregnancy rate (0% vs. 0.91%) as compared to the control group. The cumulative pregnancy rates were all higher in patients administered with GnRH-a than those without GnRH-a treatment in different cycles (one cycle: 17.07% vs 12.50%; two cycles: 29.27% vs 19.64%; three cycles: 31.71% vs 23.21%; ≥four cycles: 31.71% vs 23.21%), but the difference was not statistically significant. Notably, there was no more pregnancy after the third IUI cycle. The gestation weeks of delivery in the two groups were 39.09 ± 1.04 and 38.60 ± 1.17, respectively (p = .323). Nor was there difference in birth weight between the two groups (3236 ± 537 g vs 3435 ± 418 g, p = .360). CONCLUSIONS The administration of GnRH-a in patients with stage I-II endometriosis could be beneficial to the outcomes of IUI. It is recommended that IUI should be discontinued after three failed attempts. KEY MESSAGESEndometriosis is a common cause of infertility, but the exact mechanism remains unclear.The administration of GnRH-a before IUI treatment is beneficial for patients suffering from stage I-II endometriosis.After three failed attempts, IUI should be stopped in patients with stage I-II endometriosis.
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Affiliation(s)
- Kemei Zhang
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Shisi Huang
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Haiyan Xu
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Jiaou Zhang
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Ensheng Wang
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Yang Li
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Changling Zhu
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
| | - Jing Shu
- Reproductive Medicine Center, Ningbo City First Hospital, Ningbo315010, Zhejiang, China
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15
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Wessel JA, Mochtar MH, Besselink DE, Betjes H, de Bruin JP, Cantineau AEP, Groenewoud ER, Hooker AB, Lambalk CB, Kwee J, Kaaijk EM, Louwé LA, Maas JWM, Mol BWJ, van Rumste MME, Traas MAF, Goddijn M, van Wely M, Mol F. Expectant management versus IUI in unexplained subfertility and a poor pregnancy prognosis (EXIUI study): a randomized controlled trial. Hum Reprod 2022; 37:2808-2816. [PMID: 36331493 PMCID: PMC9712943 DOI: 10.1093/humrep/deac236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/31/2022] [Indexed: 11/06/2022] Open
Abstract
STUDY QUESTION For couples with unexplained subfertility and a poor prognosis for natural conception, is 6 months expectant management (EM) inferior to IUI with ovarian stimulation (IUI-OS), in terms of live births? SUMMARY ANSWER In couples with unexplained subfertility and a poor prognosis for natural conception, 6 months of EM is inferior compared to IUI-OS in terms of live births. WHAT IS KNOWN ALREADY Couples with unexplained subfertility and a poor prognosis are often treated with IUI-OS. In couples with unexplained subfertility and a relatively good prognosis for natural conception (>30% in 12 months), IUI-OS does not increase the live birth rate as compared to 6 months of EM. However, in couples with a poor prognosis for natural conception (<30% in 12 months), the effectiveness of IUI-OS is uncertain. STUDY DESIGN, SIZE, DURATION We performed a non-inferiority multicentre randomized controlled trial within the infrastructure of the Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology. We intended to include 1091 couples within 3 years. The couples were allocated in a 1:1 ratio to 6 months EM or 6 months IUI-OS with either clomiphene citrate or gonadotrophins. PARTICIPANTS/MATERIALS, SETTING, METHODS We studied heterosexual couples with unexplained subfertility and a poor prognosis for natural conception (<30% in 12 months). The primary outcome was ongoing pregnancy leading to a live birth. Non-inferiority would be shown if the lower limit of the one-sided 90% risk difference (RD) CI was less than minus 7% compared to an expected live birth rate of 30% following IUI-OS. We calculated RD, relative risks (RRs) with 90% CI and a corresponding hazard rate for live birth over time based on intention-to-treat and per-protocol (PP) analysis. MAIN RESULTS AND THE ROLE OF CHANCE Between October 2016 and September 2020, we allocated 92 couples to EM and 86 to IUI-OS. The trial was halted pre-maturely owing to slow inclusion. Mean female age was 34 years, median duration of subfertility was 21 months. Couples allocated to EM had a lower live birth rate than couples allocated to IUI-OS (12/92 (13%) in the EM group versus 28/86 (33%) in the IUI-OS group; RR 0.40 90% CI 0.24 to 0.67). This corresponds to an absolute RD of minus 20%; 90% CI: -30% to -9%. The hazard ratio for live birth over time was 0.36 (95% CI 0.18 to 0.70). In the PP analysis, live births rates were 8 of 70 women (11%) in the EM group versus 26 of 73 women (36%) in the IUI-OS group (RR 0.32, 90% CI 0.18 to 0.59; RD -24%, 90% CI -36% to -13%) in line with inferiority of EM. LIMITATIONS, REASONS FOR CAUTION Our trial did not reach the planned sample size, therefore the results are limited by the number of participants. WIDER IMPLICATIONS OF THE FINDINGS This study confirms the results of a previous trial that in couples with unexplained subfertility and a poor prognosis for natural conception, EM is inferior to IUI-OS. STUDY FUNDING/COMPETING INTEREST(S) The trial was supported by a grant of the SEENEZ healthcare initiative. The subsidizing parties were The Dutch Organisation for Health Research and Development (ZonMW 837004023, www.zonmw.nl) and the umbrella organization of 10 health insurers in The Netherlands. E.R.G. receives personal fees from Titus Health care outside the submitted work. M.G. declares unrestricted research and educational grants from Guerbet, Merck and Ferring not related to the presented work, paid to their institution VU medical centre. A.B.H. reports receiving travel and speakers fees from Nordic Pharma and Merck and he is member of the Nordic Pharma ANGEL group and of the Safety Monitoring Board of Womed. C.B.L. reports speakers fee from Inmed and Yingming, and his department receives research grants from Ferring, Merck and Guerbet paid to VU medical centre. B.W.J.M. is supported by a NHMRC Investigator grant (GNT1176437) and reports consultancy for ObsEva and Merck. M.v.W. received a grant from the Netherlands Organisation for Health Research and Development ZonMW (80-8520098-91072). F.M. received two grants from the Netherlands Organisation for Health Research and Development ZonMW (NTR 5599 and NTR 6590). The other authors report no competing interest. TRIAL REGISTRATION NUMBER Dutch Trial register NL5455 (NTR5599). TRIAL REGISTRATION DATE 18 December 2015. DATE OF FIRST PATIENT’S ENROLMENT 26 January 2017.
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Affiliation(s)
- J A Wessel
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M H Mochtar
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - D E Besselink
- Department of Obstetrics & Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - H Betjes
- Department Obstetrics and Gynaecology, Flevo Hospital, Almere, The Netherlands
| | - J P de Bruin
- Department of Gynaecology & Obstetrics, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - A E P Cantineau
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology & Reproductive Medicine, Noordwest Ziekenhuisgroep, Den Helder, The Netherlands
| | - A B Hooker
- Department of Obstetrics and Gynaecology, Zaans Medical Center, Zaandam, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - J Kwee
- Department of Obstetrics and Gynaecology, OLVG West, Amsterdam, The Netherlands
| | - E M Kaaijk
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, The Netherlands
| | - L A Louwé
- Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W M Maas
- Department of Obstetrics and Gynaecology MUMC+ and Grow-school of Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia,Aberdeen Centre for Women’s Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - M Goddijn
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M van Wely
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - F Mol
- Correspondence address. Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail:
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16
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Shingshetty L, Maheshwari A, McLernon DJ, Bhattacharya S. Should we adopt a prognosis-based approach to unexplained infertility? Hum Reprod Open 2022; 2022:hoac046. [PMID: 36382011 PMCID: PMC9662706 DOI: 10.1093/hropen/hoac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/09/2022] [Indexed: 08/27/2023] Open
Abstract
The treatment of unexplained infertility is a contentious topic that continues to attract a great deal of interest amongst clinicians, patients and policy makers. The inability to identify an underlying pathology makes it difficult to devise effective treatments for this condition. Couples with unexplained infertility can conceive on their own and any proposed intervention needs to offer a better chance of having a baby. Over the years, several prognostic and prediction models based on routinely collected clinical data have been developed, but these are not widely used by clinicians and patients. In this opinion paper, we propose a prognosis-based approach such that a decision to access treatment is based on the estimated chances of natural and treatment-related conception, which, in the same couple, can change over time. This approach avoids treating all couples as a homogeneous group and minimizes unnecessary treatment whilst ensuring access to those who need it early.
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Affiliation(s)
- Laxmi Shingshetty
- Aberdeen Centre for Reproductive Medicine, NHS Grampian, Aberdeen, UK
| | - Abha Maheshwari
- Aberdeen Centre for Reproductive Medicine, NHS Grampian, Aberdeen, UK
| | - David J McLernon
- Medical Statistics Team, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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17
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Prevention of multiple pregnancies in gonadotropin-insemination cycles. Curr Opin Obstet Gynecol 2022; 34:101-106. [PMID: 35645007 DOI: 10.1097/gco.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although elective single embryo transfer has significantly reduced, the rate of multiple pregnancy in IVF cycles, this rate is still relatively high in gonadotropin-insemination cycles. Patients who fail to ovulate or to conceive with oral agents and have constraints for IVF are usually candidates for gonadotropin injections. The current review article provides an up-to-date summation of the different strategies that can be adopted to reduce the risk of multiple pregnancies in gonadotropin-stimulated intrauterine insemination cycles. RECENT FINDINGS Gonadotropin-insemination treatments should be used judiciously by experienced providers. One should always start with the lowest effective gonadotropin dose (∼37.5 IU), monitor closely the ovarian response, and consider cycle cancellation or conversion to IVF whenever a high response is encountered. Therefore, every infertility practice should define its own cancellation and 'rescue IVF' criteria depending on the number of mature ovarian follicles and the age of the female partner. SUMMARY These preventive measures amongst others should mitigate the risk of multiple pregnancies that can arise from gonadotropin-insemination cycles.
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18
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Cook K, Perkins NJ, Schisterman E, Haneuse S. A multistate competing risks framework for preconception prediction of pregnancy outcomes. BMC Med Res Methodol 2022; 22:156. [PMID: 35637547 PMCID: PMC9150288 DOI: 10.1186/s12874-022-01589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 03/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Preconception pregnancy risk profiles—characterizing the likelihood that a pregnancy attempt results in a full-term birth, preterm birth, clinical pregnancy loss, or failure to conceive—can provide critical information during the early stages of a pregnancy attempt, when obstetricians are best positioned to intervene to improve the chances of successful conception and full-term live birth. Yet the task of constructing and validating risk assessment tools for this earlier intervention window is complicated by several statistical features: the final outcome of the pregnancy attempt is multinomial in nature, and it summarizes the results of two intermediate stages, conception and gestation, whose outcomes are subject to competing risks, measured on different time scales, and governed by different biological processes. In light of this complexity, existing pregnancy risk assessment tools largely focus on predicting a single adverse pregnancy outcome, and make these predictions at some later, post-conception time point. Methods We reframe the individual pregnancy attempt as a multistate model comprised of two nested multinomial prediction tasks: one corresponding to conception and the other to the subsequent outcome of that pregnancy. We discuss the estimation of this model in the presence of multiple stages of outcome missingness and then introduce an inverse-probability-weighted Hypervolume Under the Manifold statistic to validate the resulting multivariate risk scores. Finally, we use data from the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial to illustrate how this multistate competing risks framework might be utilized in practice to construct and validate a preconception pregnancy risk assessment tool. Results In the EAGeR study population, the resulting risk profiles are able to meaningfully discriminate between the four pregnancy attempt outcomes of interest and represent a significant improvement over classification by random chance. Conclusions As illustrated in our analysis of the EAGeR data, our proposed prediction framework expands the pregnancy risk assessment task in two key ways—by considering a broader array of pregnancy outcomes and by providing the predictions at an earlier, preconception intervention window—providing obstetricians and their patients with more information and opportunities to successfully guide pregnancy attempts.
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Merviel P, Labarre M, James P, Bouée S, Chabaud JJ, Roche S, Cabry R, Scheffler F, Lourdel E, Benkhalifa M, Copin H, Drapier H, Beauvillard D. Should intrauterine inseminations still be proposed in cases of unexplained infertility? Retrospective study and literature review. Arch Gynecol Obstet 2022; 305:1241-1254. [PMID: 34981203 DOI: 10.1007/s00404-021-06351-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/24/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Unexplained infertility is defined by the absence of identifiable causes of infertility. The results of randomized studies and meta-analysis regarding the treatment of unexplained infertility are discordant due to methodological problems. DESIGN The aim of this study is to compare the clinical pregnancy rate per cycle (CPR/c) in IUI and IVF/ICSI in cases of unexplained infertility, according to the woman's age group and to identify the factors which predict success. INTERVENTIONS We performed a retrospective study in two ART centers, comparing overall clinical pregnancy, ongoing pregnancy and live birth rates in IVF/ICSI and IUI. We also compared pregnancy and birth rates according to different female age groups. RESULTS 855 IVF/ICSI and 804 IUI cycles were compared. We found a significant difference (p < 0.001) in the pregnancy and live birth rates per cycle between IUI and IVF/ICSI, overall and in the different female age groups, except in women aged 40 and over. The greatest chances of pregnancy with IUI are found in women with secondary unexplained infertility, during the first two cycles and with a bi-follicular response to stimulation. In IVF/ICSI, pregnancy rates are higher in women with secondary unexplained infertility, in the first two cycles, in IVF and in women receiving a transfer of two embryos regardless of the embryonic stage. CONCLUSION We recommend IVF/ICSI treatment rather than IUI for unexplained infertility (OR CPR/c 4.20 with 95% CI [3.72-4.68]). This is in accordance with NICE, which advises the use of IVF after 2 years.
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Affiliation(s)
- Philippe Merviel
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France.
| | - Marion Labarre
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Pandora James
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Sarah Bouée
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | | | - Sylvie Roche
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Rosalie Cabry
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Florence Scheffler
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Emmanuelle Lourdel
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Moncef Benkhalifa
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Henri Copin
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Hortense Drapier
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Damien Beauvillard
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
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20
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He W, Chen S, Huang J, Zhang X, Hu L, Xue Z, Qiu Y. Association Between Type of Infertility and Live Birth in Couples With a Single Intrauterine Insemination Resulting in Pregnancy: A Propensity Score Matching Cohort Study. Front Endocrinol (Lausanne) 2022; 13:926183. [PMID: 35909526 PMCID: PMC9329630 DOI: 10.3389/fendo.2022.926183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies have described the relationship between the type of infertility and live birth in patients treated with intrauterine insemination (IUI). We focused on this issue and attempted to explore it. METHODS This retrospective study enrolled 2,256 infertile patients who underwent their first IUI cycle and were subsequently diagnosed with a clinical pregnancy at Ji'an Women and Child Health Care Hospital between 2007 and 2018. Inductees were divided into primary infertility (1,680 patients) and secondary infertility groups (876 patients). Following 1:1 propensity score matching to obtain balanced data, the COX proportional hazards model, landmark analysis, and subgroup analysis were used to assess the association between infertility types and live birth rates. Subsequently, a sensitivity analysis was employed to evaluate the potential effect of unmeasured confounding on outcomes. RESULTS Of the 1,486 patients who were identified as a matched cohort, 743 were in the primary infertility group and the remaining patients were in another group. A total of 1,143 patients had live births during 431,009 person-days of follow-up (average 290.0 days). Throughout the follow-up period, patients with secondary infertility demonstrated more live births than patients with primary infertility (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.04 to 1.30; P = .007). More details were observed in the landmark analysis. Live birth rates were similar in both groups within 316 days of follow-up (HR, 0.84; 95% CI, 0.62 to 1.14; P = .269), whereas the opposite was found between 316 days of follow-up and delivery day (HR, 1.19; 95% CI, 1.06 to 1.34; P = .004). This was also obtained in a subgroup analysis of patients younger than 35 years old and patients treated with natural cycles (NCs) and IUIs. CONCLUSION Among the infertile patients who underwent a single natural or stimulated cycle followed by IUI and had later pregnancies, full-term young secondary infertility mothers (<35 years of age) had a greater chance of having viable babies than the primary infertility ones. The latter may get more benefits when undergoing ovarian stimulation and IUI rather than NC-IUI.
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Affiliation(s)
- Wen He
- Department of Regenerative Medicine, Tongji University School of Medicine, Shanghai, China
| | - Song Chen
- Department of Orthopaedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jianping Huang
- Reproductive Medicine Center, Ji’an Women and Child Health care Hospital, Jiangxi, China
| | - Xiaofang Zhang
- Reproductive Medicine Center, Ji’an Women and Child Health care Hospital, Jiangxi, China
| | - Lili Hu
- Reproductive Medicine Center, Ji’an Women and Child Health care Hospital, Jiangxi, China
| | - Zhigang Xue
- Department of Regenerative Medicine, Tongji University School of Medicine, Shanghai, China
- Reproductive Medicine Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Zhigang Xue, ; Yu Qiu,
| | - Yu Qiu
- Reproductive Medicine Center, Ji’an Women and Child Health care Hospital, Jiangxi, China
- *Correspondence: Zhigang Xue, ; Yu Qiu,
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21
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Ombelet W, Van der Auwera I, Bijnens H, Onofre J, Kremer C, Bruckers L, Mestdagh G, Campo R, Dhont N. Improving IUI success by performing modified slow-release insemination and a patient-centred approach in an insemination programme with partner semen: a prospective cohort study. Facts Views Vis Obgyn 2021; 13:359-367. [PMID: 35026097 PMCID: PMC9148711 DOI: 10.52054/fvvo.13.4.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Pregnancy rates after in vitro fertilisation (IVF) treatment continue to improve, while intrauterine insemination (IUI) programmes show no such trend. There is a need to improve success rates with IUI to retain it as a viable option for couples who prefer avoiding IVF as a first line treatment. Objective To investigate if a modified slow-release insemination (SRI) increases the clinical pregnancy rate (CPR) after intrauterine insemination (IUI) with partner semen. Materials and Methods This was a prospective cohort study in a Belgian tertiary fertility centre. Between July 2011 and December 2018, we studied data from an ongoing prospective cohort study including 989 women undergoing 2565 IUI procedures for unexplained or mild/moderate male infertility. These data were analysed in order to study the importance of different covariates influencing IUI success. Generalised estimating equations (GEEs) were used for statistical analysis. Results of two periods (2011-2015, period 1 and 2016-2018, period 2) were examined and compared. From January 2016 (period 2) onwards, a standardised SRI procedure instead of bolus injection of sperm was applied. The primary outcome parameter was the difference in clinical pregnancy rate (CPR) per cycle between period 1 (bolus IUI) and period 2 (modified SRI). Secondary outcome results included all other parameters significantly influencing CPR after IUI. Results Following the application of modified SRI the CPR increased significantly, from 9.03% (period 1) to 13.52% (period 2) (p = 0.0016). Other covariates significantly influencing CPR were partner’s age, smoking/ non-smoking partner, BMI patient, ovarian stimulation protocol and Inseminating Motile Count (after semen processing). Conclusion The intentional application of modified slow-release of processed semen appears to significantly increase CPRs after IUI with homologous semen. Future studies should investigate whether SRI, patient-centred measures, or a combination of both, are responsible for this improvement.
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Su T, Wang H, Yao Y. Novel nucleic acid aptamer gold (Au)-nanoparticles (AuNPs-AptHLA-G5-1 and AuNPs-AptHLA-G5-2) to detect the soluble human leukocyte antigen G5 subtype (HLA-G5) in liquid samples. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1416. [PMID: 34733968 PMCID: PMC8506699 DOI: 10.21037/atm-21-3334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Abstract
Background The human leukocyte antigen G5 subtype (HLA-G5) is a major histocompatibility complex (MHC) molecule that is selectively expressed at the maternal-foetal tissue interface and is required for the successful implantation of the in vitro fertilized embryo. It is critical to detect HLA-G5, especially HLA-G5 expression in embryo fluid, during in vitro embryo incubation and culture. However, the specificity and sensitivity of traditional ELISA methods to detect sHLA-G5 are insufficient. This work aimed to explore novel nucleic acid aptamer gold (Au)-nanoparticles to detect soluble HLA-G5 in liquid samples. Methods Soluble HLA-G5 was obtained using a prokaryotic expression system, and two novel aptamers (HLA-G5-Apt1 and HLA-G5-Apt2) detecting HLA-G5 were screened by the Systematic Evolution of Ligands by Exponential Enrichment (SELEX) method. Small (10 nm) gold nanoparticles (AuNPs) were incubated with AptHLAs to form two novel nucleic acid aptamers: Au-nanoparticles (AuNPs-AptHLA-G5-1 and AuNPs-AptHLA-G5-2). Results The results showed that AptHLA-G5-1 and AptHLA-G5-2 have a high affinity for HLA-G5 and can detect its presence in liquid samples. Using the colorimetric sensing method, AuNPs-AptHLA-G1 had a detection limit as low as 20 ng/mL (recovery range between 98.7% to 102.0%), while AuNPs-AptHLA-G2 had a detection limit as low as 20 ng/mL (recovery range between 98.9% to 103.6%). Conclusions Our work demonstrates that novel AuNPs are efficient detectors for HLA-G5 and are useful for diagnosis and treatment in the field of obstetrics-gynaecology.
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Affiliation(s)
- Tao Su
- Medical School of Chinese PLA & Reproductive Center, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hui Wang
- Medical School of Chinese PLA & Reproductive Center, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yuanqing Yao
- Medical School of Chinese PLA & Reproductive Center, the First Medical Center of Chinese PLA General Hospital, Beijing, China
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Expectant Management Before In vitro Fertilization in Women Aged 39 or Above and Unexplained Infertility Does Not Decrease Live Birth Rates Compared to Immediate Treatment. Reprod Sci 2021; 29:1232-1240. [PMID: 34724170 PMCID: PMC8559689 DOI: 10.1007/s43032-021-00767-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/04/2022]
Abstract
Unexplained infertile couples can have further expectant management before starting assisted reproductive treatments. However, ovarian reserve and in vitro fertilization (IVF) outcomes rapidly decline after 39 years or more. It is thus important to clarify whether a waiting policy is also appropriate for women of advanced age. Couples who had access to a waiting list for approximately 1 year before receiving reimbursed public IVF were compared with those paying for access to immediate treatment. To allow for comparisons between these two strategies, we followed up couples who opted to pay for 1 year after the last embryo transfer from their first cycle. We calculated the proportion of live births in both groups and compared these using logistic regression models and a two-sample Z test for equality of proportions. Six hundred thirty-five couples were evaluated. Out of 359 couples in the immediate group, 70 (19.5%) had a live birth of which 11 after natural conception and 59 after IVF. Out of 276 couples in the waiting group, 57 (20.7%) had a live birth of which 37 after natural conception and 20 after IVF. There was no statistically significant difference between the two strategies in terms of the crude cumulative live birth rate (cLBR). The adjusted odds ratio of 0.69 (95%CI:0.39–1.22) did not change this conclusion as our sensitivity analyses. The cLBR for the ‘waiting before IVF’ and the ‘immediate’ strategies were similar. Further studies are needed to better characterize couples affected by unexplained infertility in order to individualize treatment strategies.
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Madhuri MS, Thyagaraju C, Naidu A, Dasari P. The effect of endometrial scratching on pregnancy rate after failed intrauterine insemination: A Randomised Controlled Trail. Eur J Obstet Gynecol Reprod Biol 2021; 268:37-42. [PMID: 34798531 DOI: 10.1016/j.ejogrb.2021.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/07/2021] [Accepted: 10/24/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Endometrial injury (ES) has been suggested as intervention to increase probability of pregnancy in women undergoing assisted reproductive technologies. Majority of studies reported that ES improves outcome in Invitro fertilisation,Intrauterine Insemination(IUI) and natural conceptions: however, the size and quality of studies are poor which questions the presence of any beneficial effect. The present study was done to evaluate the effect of endometrial scratching on pregnancy rate after previous failed Intrauterine Insemination and to assess the pain and bleeding following the procedure. MATERIAL AND METHODS Randomized controlled trial. One hundred sixty-eight women (Eighty-four in each group) with primary/secondary infertility were recruited and randomized into intervention and control group using block randomization. Intervention group underwent ES using pipelle's canula on D8 or D9 of menstrual cycle. Three cycles of ovulation induction with Clomiphene citrate and gonadotrophins followed by IUI was done. The primary end point was clinical pregnancy rate. Pain and bleeding after the procedure were evaluated as secondary outcomes.The study was conducted from June 2017 to June 2019. MAIN RESULTS The cumulative clinical pregnancy rate in ES group was 22.2 % in comparison 9.8 % in control group. In the intent to treat analysis, with a p value of 0.03 calculated from Chi-square test(p < 0.05) there was statistically significant difference in the pregnancy rate between Intervention and Control group. Efficacy of intervention was found to be Fourteen Percent (14 %). Fifty-one women (63 %) had marked a VAS pain score of 4-5 and Twelve women(12.2 %) experienced mild spotting post procedure. Two patients in ES group had miscarriage and no case of multiple pregnancy in both the groups. CONCLUSION Endometrial Scratching improves clinical pregnancy rate in patients with Unexplained infertility and mild male factor infertility with previous failed IUI cycles. ES will be an inexpensive alternative to IVF for couples after IUI failures especially in developing countries, with an acceptable pregnancy rate and does not demand any special qualification or equipment and can be trained easily in primary settings. Larger and adequately powered studies are needed to elucidate the beneficial effects of endometrial scratching on implantation.
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Affiliation(s)
- M S Madhuri
- Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| | - Chitra Thyagaraju
- Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India.
| | - Archana Naidu
- Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| | - Papa Dasari
- Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
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Nandi A, Raja G, White D, Tarek ET. Intrauterine insemination + controlled ovarian hyperstimulation versus in vitro fertilisation in unexplained infertility: a systematic review and meta-analysis. Arch Gynecol Obstet 2021; 305:805-824. [PMID: 34636983 DOI: 10.1007/s00404-021-06277-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 10/01/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND IUI + COH is widely used in cases of unexplained infertility before resorting to IVF. Debate continues about what should be the first-line treatment for couples with unexplained infertility. OBJECTIVES This systematic review assessed the relative efficacy of IUI + COH compared with IVF in couples with unexplained infertility. SEARCH STRATEGY We searched Medline, Embase, CIHNL, Pscy Info, and Cochrane Library from 1980 to November 2019. SELECTION CRITERIA Only RCTs published articles in full text with female patients aged 18-43 years and diagnosed with unexplained infertility were included. DATA COLLECTION AND ANALYSIS Two authors reviewed citations from primary search independently and any disagreement was resolved by mutual discussion and consultation with a third author. MAIN RESULT In total, eight RCTs were included. The quality of evidence was moderate to low due to inconsistency across the trials and imprecision. The pooled result showed that IVF was associated with a statistically significant higher live birth rate (RR 1.53, 95% CI 1.01-2.32, P < 0.00001 I2 = 86%) with no significant difference in multiple pregnancy rate or OHSS rate. Sensitivity analysis based on women's age and a history of previous IUI or IVF treatment showed no significant difference in the live birth rates (RR 1.01, 95% CI 0.88-1.15, I2 = 0%, 3 RCTs) in treatment-naïve women younger than 38 years. In women over 38 years, the live birth rates were significantly higher in the IVF group (RR 2.15, 95% CI 1.16-4.0, I2 = 42%, 1 RCT). CONCLUSION Further research using a standardised treatment protocol and taking into account important prognostic variables and cumulative live birth rates from fresh IVF and all sibling frozen embryos is required to further guide clinical practice.
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Affiliation(s)
- Anupa Nandi
- Assisted Conception Unit, Great Maze Pond, Guy's and St Thomas' Hospital NHS Trust, London, SE1 9RT, UK.
| | - Gangopadhyay Raja
- Department of Obstetrics and Gynaecology, Watford General Hospital, Hertfordshire, UK
| | - Davinia White
- Assisted Conception Unit, Great Maze Pond, Guy's and St Thomas' Hospital NHS Trust, London, SE1 9RT, UK
| | - El-Toukhy Tarek
- Assisted Conception Unit, Great Maze Pond, Guy's and St Thomas' Hospital NHS Trust, London, SE1 9RT, UK
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Wang X, Zhang Y, Sun HL, Wang LT, Li XF, Wang F, Wang YL, Li QC. Factors Affecting Artificial Insemination Pregnancy Outcome. Int J Gen Med 2021; 14:3961-3969. [PMID: 34349545 PMCID: PMC8326936 DOI: 10.2147/ijgm.s312766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/07/2021] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of the present study was to explore related clinical pregnancy outcome factors in intrauterine insemination (IUI). Materials and Methods The clinical data of 3984 IUI cycles in 1862 couples experiencing infertility who attended the Reproductive Center of Binzhou Medical University Hospital between July 2006 and July 2017 were retrospectively analyzed. Female and male patient age, endometrial thickness (EMT), the post-wash total motile sperm count (PTMC), artificial insemination timing, insemination frequency, and ovarian stimulation protocols were compared between the study’s pregnant group and non-pregnant group in order to explore any correlation. Results There were statistically significant differences in female and male age, EMT, artificial insemination timing, insemination frequency, and ovarian stimulation protocols between the two groups (p < 0.05). The clinical pregnancy rate was significantly higher in ovarian stimulation cycles than in natural cycles (21.2% and 11.6%, respectively; p < 0.01), the clinical pregnancy rate was significantly higher in double IUI than in single IUI (17.8% and 12.1%, respectively; p < 0.01), and EMT was significantly greater in the pregnant group than in the control group (p < 0.05). However, the differences in clinical pregnancy rates among the PTMC groups were not statistically significant (14.8%, 14.4%, 17.3%, and 17.3%, respectively; p > 0.05). Conclusion The results of the present study demonstrate that the clinical IUI pregnancy rate is correlated with the factors of female age, male age, EMT, artificial insemination timing, insemination frequency, and ovarian stimulation protocols; the ovarian stimulation protocol can noticeably improve the patient pregnancy outcome. Furthermore, compared with single IUI, double IUI can significantly increase the clinical pregnancy rate.
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Affiliation(s)
- Xue Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Yue Zhang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Hong-Liang Sun
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Li-Ting Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Xue-Feng Li
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Fei Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Yan-Lin Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Qing-Chun Li
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
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Baradwan S, Alshahrani MS, Miski NT, Alkhamis WH, Alfaifi SS, Abdelhakim AM, Sunoqrot M, Ahmaro M, Abdelazem O, Mohammed AH, Abbas AM, Bakry MS. Ultrasound guidance versus classical method for intrauterine insemination: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2021; 263:223-230. [PMID: 34242930 DOI: 10.1016/j.ejogrb.2021.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There is a great controversy regarding the benefits of ultrasound-guided intrauterine insemination (IUI) in improving pregnancy rates. Thus, we aimed to compare ultrasound-guided IUI versus classical IUI regarding the pregnancy rates improvement. METHODS A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during June 2021. We selected randomized clinical trials (RCTs) that compared ultrasound-guided IUI versus classical IUI in different pregnancy outcomes. We extracted the available data from included studies and pooled them in a meta-analysis model using RevMan software. Our primary outcome was clinical pregnancy rate. Our secondary outcomes were miscarriage, live birth rates, and incidence of difficulty reported during the procedure. The overall quality of evidence was assessed through GRADEpro GDT software. RESULTS Seven RCTs met our inclusion criteria with a total number of 1338 patients. We found that ultrasound-guided IUI significantly improved the clinical pregnancy rate when compared to the classical group (RR = 1.33, 95% CI [1.05, 1.68], p = 0.02). However, there were no significant differences between both groups in terms of miscarriage and live birth rates. Ultrasound-guided IUI significantly reduced the incidence of difficulty reported during the procedure (RR = 0.42, 95% CI [0.21, 0.84], p = 0.01). The GRADEpro GDT tool showed high quality of evidence for the evaluated outcomes. CONCLUSIONS There is evidence of high quality that ultrasound-guided IUI improves the pregnancy rate and reduces the incidence of difficulty reported during the procedure.
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Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Majed Saeed Alshahrani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Najran University, Najran, Saudi Arabia
| | - Najlaa Talat Miski
- Department of Obstetrics and Gynecology, Faculty of Medicine at Rabigh, King Abdulaziz University, Saudi Arabia
| | - Waleed H Alkhamis
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Suhail S Alfaifi
- Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Mohammad Sunoqrot
- College of Medicine and Health Sciences, Palestine Polytechnic University, Hebron, Palestine
| | - Manar Ahmaro
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Osama Abdelazem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Ahmed Hashim Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Egypt
| | - Mohamed Sobhy Bakry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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Osmanlıoğlu Ş, Şükür YE, Tokgöz VY, Özmen B, Sönmezer M, Berker B, Aytaç R, Atabekoğlu CS. Intrauterine insemination with ovarian stimulation is a successful step prior to assisted reproductive technology for couples with unexplained infertility. J OBSTET GYNAECOL 2021; 42:472-477. [PMID: 34151684 DOI: 10.1080/01443615.2021.1916805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The present retrospective cohort study analysed data of couples with unexplained infertility who underwent two to three intrauterine insemination (IUI) cycles. The inclusion criteria were age 20-40 years, failure to conceive for at least two years of unprotected intercourse, ovulation, normal semen analysis, and tubal patency. Total of 578 IUI cycles of 286 couples with unexplained infertility were included in the final analyses. The mean age and duration of infertility of the study population were 28.8 ± 5.1 and 5.2 ± 3.4 years, respectively. The clinical pregnancy rate (CPR) and live birth rate (LBR) per cycle were 16.6 and 13.1%, respectively. The cumulative CPR following two to three IUI cycles was 33.5% and the cumulative LBR was 26.5% for the entire cohort. The duration of infertility was significantly shorter in women whose IUI attempt were successful (p = .036). Up to three cycles of IUI with ovarian stimulation seems as an effective first-line treatment modality in unexplained infertility.IMPACT STATEMENTWhat is already known on this subject? Cont rolled ovarian stimulation combined with intrauterine insemination (IUI) is a common infertility treatment as a low-cost, less-invasive alternative to in vitro fertilisation (IVF) and was approved as a first line treatment option for unexplained infertility However, the UK National Institute for Health and Care Excellence (NICE) guideline states that IUI is not recommended to couples with unexplained infertility, male factor and mild endometriosis, unless the couples have religious, cultural or social objections to proceed with IVF.What do the results of this study add? Up to three IUI cycles with ovarian stimulation can be considered as an effective treatment modality in unexplained infertility even in couples who could not achieve pregnancy by expectant management for two years.What are the implications of these findings for clinical practice and/or further research? The clinicians should reconsider the NICE recommendation of IVF in the light of recent studies including ours which recommend IUI together when dealing couples with unexplained infertility.
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Affiliation(s)
- Şeyma Osmanlıoğlu
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara Medipol University, Ankara, Turkey
| | - Yavuz Emre Şükür
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara University, Ankara, Turkey
| | - Vehbi Yavuz Tokgöz
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Batuhan Özmen
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara University, Ankara, Turkey
| | - Murat Sönmezer
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara University, Ankara, Turkey
| | - Bülent Berker
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara University, Ankara, Turkey
| | - Ruşen Aytaç
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara University, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Faculty of Medicine, Department of Gynaecology and Obstetrics, Ankara University, Ankara, Turkey
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Ombelet W, van Eekelen R, McNally A, Ledger W, Doody K, Farquhar C. Should couples with unexplained infertility have three to six cycles of intrauterine insemination with ovarian stimulation or in vitro fertilization as first-line treatment? Fertil Steril 2021; 114:1141-1148. [PMID: 33280720 DOI: 10.1016/j.fertnstert.2020.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Willem Ombelet
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Rik van Eekelen
- Centre for Reproductive Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, the Netherlands
| | - Aine McNally
- Department of Clinical Reproductive Endocrinology and Infertility, St. George Hospital, Kogarah, Sydney, Australia
| | - William Ledger
- Department of Obstetrics and Gynecology and Reproductive Medicine, University of New South Wales, Royal Hospital for Women, Randwick, Sydney, Australia
| | - Kevin Doody
- Center for Assisted Reproduction, Bedford, Texas
| | - Cynthia Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand; Fertility Plus, Auckland District Health Board, Auckland, New Zealand.
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Firouz M, Noori N, Ghasemi M, Dashipour A, Keikha N. Comparing the Effectiveness of Doing Intra-uterine Insemination 36 and 42 Hours After Human Chorionic Gonadotropin (HCG) Injection on Pregnancy Rate: A Randomized Clinical Trial. J Family Reprod Health 2021; 14:173-179. [PMID: 33603809 PMCID: PMC7868649 DOI: 10.18502/jfrh.v14i3.4670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: Intrauterine insemination (IUI) is an assisted conception technique that involves the deposition of a processed semen sample in the upper uterine cavity, overcoming natural barriers to sperm ascent in the female reproductive tract. Hence, we compared the results of doing intra-uterine insemination 36 and 42 hours after human chorionic gonadotropin (hCG) hormone injection to achieve clinical and chemical pregnancy rates. Materials and methods: One hundred and sixty infertile women with unexplained infertility participated in this clinical trial. They were divided into two groups: those who underwent IUI 36 hours after hCG injection (control group), and those who underwent IUI 42 hours after hCG injection (case group). Statistical analyses were done using IBM-SPSS 25.0. and Chi-square test were used for data analysis. Results: The percentages of clinical and chemical pregnancies were significantly higher in the 42h group compared to the other group (P = 0.038 vs. P = 0.009, respectively). There was no significant difference regarding frequency of abortion, twin and ectopic pregnancies between the two groups (P > 0.05). Conclusion: Doing IUI 42 hours after hCG injection can significantly increase chances of fertility compared to doing it 36 hours after hCG injection.
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Affiliation(s)
- Mahboubeh Firouz
- Department of Obstetrics and Gynecology, Ali Ibn Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Narjes Noori
- Department of Obstetrics and Gynecology, Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Marzieh Ghasemi
- Department of Obstetrics and Gynecology, Ali Ibn Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran.,Moloud Infertility Center, Ali Ibn Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Alireza Dashipour
- Cellular and Molecular Research Center, Department of Clinical Biochemistry, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Narjes Keikha
- Moloud Infertility Center, Ali Ibn Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
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Mathews DM, Johnson NP, Sim RG, O'Sullivan S, Peart JM, Hofman PL. Iodine and fertility: do we know enough? Hum Reprod 2021; 36:265-274. [PMID: 33289034 DOI: 10.1093/humrep/deaa312] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/30/2020] [Indexed: 02/01/2023] Open
Abstract
Iodine is a vital micronutrient and its importance in thyroid function is well established. However, abnormalities in iodine intake may also have other effects. In particular, iodine is taken up avidly by the ovary and endometrium. Iodine deficiency is associated with reduced fertility. The use of high iodine concentration contrast media has recently been shown to improve conception rates in couples with unexplained infertility (UI). We hypothesize that this improvement could be related to the iodine excess and mechanisms independent of its action on thyroid. In this article, the metabolism of iodine and its potential role in fertility will be discussed, including the impact of both iodine deficiency and excess states and the importance of iodine in normal fetal development. This will include insights from animal studies on the effect of iodine in the uterine and ovarian structural environment, hormonal milieu and immunological factors affecting implantation. We speculate that iodine may well have a role as a potential therapy for UI.
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Affiliation(s)
- Divya M Mathews
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Neil P Johnson
- Robinson Research Institute, University of Adelaide, Australia and University of Auckland & Repromed Auckland, Auckland, New Zealand
| | | | - Susannah O'Sullivan
- Endocrinology, Greenlane Clinical Centre, Auckland District Health Board, Auckland, New Zealand
| | | | - Paul L Hofman
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Wu Y, Liu H, Liu J. The Livebirth Rate Per In Vitro Fertilization Cycle Is Higher Than The Cumulative Live Birth Rates of Intrauterine Insemination for Patients of Poseidon Group 3 With Unexplained Infertility. Front Endocrinol (Lausanne) 2021; 12:768975. [PMID: 34925238 PMCID: PMC8671868 DOI: 10.3389/fendo.2021.768975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND No studies have been done to examine the efficacy of IVF and intrauterine insemination (IUI) for the treatment of young patients with unexplained infertility and low ovarian reserve, although it is becoming an increasingly significant indication for in-vitro fertilization (IVF). The goal of this research was to compare the efficacy of IVF with IUI on Poseidon group 3 patients with unexplained infertility (PG3&UI). METHODS This was a retrospective analysis of PG3&UI patients who had IVF/intracytoplasmic sperm injection (ICSI) or IUI at the Third Affiliated Hospital of Guangzhou Medical University between January 1, 2015, and March 31, 2021. To equalize the baseline characteristics of the IVF/ICSI and IUI groups, propensity score matching (PSM) was utilized. Intention-to-treat (ITT) and per-protocol (PP) analyses were used to compare the differences in live births. To discover variations in time to biochemical pregnancy leading to live birth, Kaplan-Meier curves were produced. To evaluate the expenses per live birth between two procedures, a cost-effective analysis was done. RESULTS According to ITT analysis, the live birth rate for the IVF/ICSI group was substantially higher than the cumulative live birth rate (CLBR) for the IUI group (22.6% (38/168) vs. 11.3% (19/168), RR 2.00, 95% CI 1.20-3.32, P = 0.006). In the PP analysis, the live birth rate was 23.0% (38/165) in the IVF/ICSI group and 11.7% (19/162) in the IUI group (RR = 1.96, 95% CI 1.18-3.26, P = 0.007). When censored at 365 days, the Kaplan-Meier analysis revealed that the IVF/ICSI group had a higher live birth rate than the IUI group (log-rank test χ²= 6.025; P = 0.014). However, when the two groups were censored at 180 days, the live birth rates were not substantially different (log-rank test χ²= 3.847; P = 0.05). The number of hospital visits per live birth in the IUI group was higher than in the IVF/ICSI group (85 vs. 48). The overall cost of a live birth was comparable across the two groups (¥132242 vs. ¥131611), while the medical expenses for a live delivery from IVF/ICSI were higher than those from IUI (¥118955 vs. ¥108279). CONCLUSIONS The livebirth rate per IVF/ICSI cycle with at most one embryo transfer is higher than the CLBR of IUI, with fewer hospital visits and similar expenses.
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Affiliation(s)
| | - Haiying Liu
- *Correspondence: Haiying Liu, ; Jianqiao Liu,
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Liao S, Jin L, Dai W, Huang G, Pan W, Hu C, Pan W. A machine learning‐based risk scoring system for infertility considering different age groups. INT J INTELL SYST 2020. [DOI: 10.1002/int.22344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- ShuJie Liao
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Lei Jin
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Wan‐Qiang Dai
- School of Economic and Management Wuhan University Wuhan China
| | - Ge Huang
- School of Economic and Management Wuhan University Wuhan China
| | - Wulin Pan
- School of Economic and Management Wuhan University Wuhan China
| | - Cheng Hu
- School of Economic and Management Wuhan University Wuhan China
| | - Wei Pan
- School of Applied Economics Renmin University of China Beijing China
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Abstract
Clinically, infertility is defined as the inability to conceive after a certain period. In contrast, sterility is defined as the inability to produce a biological child; however, this is not a practical definition that can be applied in a clinical setting to a patient’s diagnosis. Unlike infertility, sterility is rarely discussed in biomedical and clinical literature and is often used synonymously with infertility. Infertility affects about 10% of couples globally, but the prevalence of sterility remains unknown. We divide sterility into three subtypes natural, clinical, and hardship. To estimate sterility prevalence, we analyzed primary literature and meta-analysis papers on the rates of live births and pregnancies throughout several treatments of infertile couples (e.g., untreated patients, in vitro fertilization-treated, and patients administered other treatments). This analysis indicates that all treatments fail in delivering a biological child to most couples, suggesting that most infertile couples may fail to conceive. More comprehensive primary studies are needed to provide a precise estimate of sterility. Furthermore, research is needed to study the causes of sterility, as well as develop methods for diagnosis and treatment that are financially affordable and emotionally tolerable. Altogether, sterility is an under-discussed condition that is more common than expected, as many infertile couples are unable to conceive and are, in effect, sterile.
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van Eekelen R, Rosielle K, van Welie N, Dreyer K, van Wely M, Mol BW, Eijkemans MJ, Mijatovic V, van Geloven N. Does the effectiveness of IUI in couples with unexplained subfertility depend on their prognosis of natural conception? A replication of the H2Oil study. Hum Reprod Open 2020; 2020:hoaa047. [PMID: 33598567 PMCID: PMC7875174 DOI: 10.1093/hropen/hoaa047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/04/2020] [Indexed: 01/09/2023] Open
Abstract
STUDY QUESTION Can we replicate the finding that the benefit of IUI-ovarian stimulation (IUI-OS) compared to expectant management for couples with unexplained subfertility depends on the prognosis of natural conception? SUMMARY ANSWER The estimated benefit of IUI-OS did not depend on the prognosis of natural conception but did depend on when treatment was started after diagnosis, with starting IUI-OS later yielding a larger absolute and relative benefit of treatment. WHAT IS KNOWN ALREADY IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials (RCTs) compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found different results. In a previous study (a Dutch national cohort), it was found that the benefit of IUI-OS compared to expectant management seemed dependent on the prognosis of natural conception, but this finding warrants replication. STUDY DESIGN SIZE DURATION We conducted a secondary analysis of the H2Oil study (n = 1119), a multicentre RCT that evaluated the effect of oil-based contrast versus water-based contrast during hysterosalpingography (HSG). Couples were randomized before HSG and followed up for 3-5 years. We selected couples with unexplained subfertility who received HSG and had follow-up or pregnancy data available. Follow-up was censored at the start of IVF, after the last IUI cycle or at last contact and was truncated at a maximum of 18 months after the fertility workup. PARTICIPANTS/MATERIALS SETTING METHODS The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month the ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting. MAIN RESULTS AND THE ROLE OF CHANCE Data from 975 couples were available. There were 587 couples who received at least one IUI-OS cycle within 18 months after HSG of whom 221 conceived leading to an ongoing pregnancy (rate: 0.74 per couple per year over a median follow-up for IUI of 5 months). The median period between HSG and starting IUI-OS was 4 months. Out of 388 untreated couples, 299 conceived naturally (rate: 0.56 per couple per year over a median follow-up of 4 months). After creating our mimicked trial datasets, starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.50 (95% CI: 1.19-1.89) compared to expectant management. We did not find strong evidence that the effect of treatment was modified by a couple's prognosis of achieving natural conception (Akaike's Information Criterion (AIC) decreased by 1 point). The effect of treatment was dependent on when couples started IUI-OS (AIC decreased by more than 2 points). The patterns of estimated absolute chances over time for couples with increasingly better prognoses were different from the previous study but the finding that starting later yields a larger benefit of treatment was similar. We found IUI-OS increased the absolute chance of pregnancy by at least 5% compared to expectant management. The absolute chance of pregnancy after IUI-OS seems less variable between couples and starting times of treatment than the absolute chance after expectant management. LIMITATIONS REASONS FOR CAUTION This is a secondary analysis, as the H2Oil trial was not designed with this research question in mind. Owing to sample size restrictions, it remained difficult to distinguish between the ranges of prognoses in which true benefit was found. WIDER IMPLICATIONS OF THE FINDINGS We replicated the finding that starting IUI-OS later after diagnosis yields a larger absolute and relative benefit of treatment. We did not replicate the dependency of the effect of IUI-OS on the prognosis of natural conception and could not identify clear thresholds for the prognosis of natural conception when IUI-OS was and/or was not effective. Because many of these couples still have good chances of natural conception at the time of diagnosis, we suggest clinicians should advise couples to delay the start of IUI-OS for several months to avoid unnecessary treatment. STUDY FUNDING/COMPETING INTERESTS The H2Oil study (NTR 3270) was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The follow-up study (NTR 6577) was also an investigator-initiated study with funding by Guerbet, France. The funders had no role in study design, collection, analysis and interpretation of the data. B.W.M. is supported by an Investigator grant (GNT1176437) from the Australian National Health and Medical Research Council (NHMRC). K.D. reports receiving travel and speaker fees from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. V.M. reports receiving travel- and speaker fees as well as research grants from Guerbet.
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Affiliation(s)
- R van Eekelen
- Amsterdam UMC, Academic Medical Centre, Centre for Reproductive Medicine, Amsterdam, the Netherlands
| | - K Rosielle
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - N van Welie
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - K Dreyer
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M van Wely
- Amsterdam UMC, Academic Medical Centre, Centre for Reproductive Medicine, Amsterdam, the Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - M J Eijkemans
- Department of Biostatistics and Research Support, Julius Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - N van Geloven
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
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Kamath MS, Rikken JFW, Bosteels J. Does Laparoscopy and Hysteroscopy Have a Place in the Diagnosis of Unexplained Infertility? Semin Reprod Med 2020; 38:29-35. [PMID: 33080633 DOI: 10.1055/s-0040-1718942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The standard fertility workup includes assessment of ovulation, semen analysis, and evaluation of tubal patency. If the fertility workup is found to be normal, a diagnosis of unexplained infertility is made. The role of laparoscopy in fertility workup has been a matter of debate. The current review presents the evidence for and against laparoscopy and hysteroscopy during fertility workup and subsequently prior to fertility treatment. After appraising the literature, we found the role of diagnostic laparoscopy in fertility workup is limited and is dependent on factors like prevalence of pelvic infection, setting, and availability of expertise. Moreover, whenever a laparoscopy is planned as a part of the fertility workup, the preparation should include ability to carry out simultaneous therapeutic intervention to maximize the benefit. Similarly, the routine use of hysteroscopy in women with unexplained infertility cannot be recommended. There is a need to investigate the impact of choice of tubal test on chances of spontaneous conception and treatment outcomes in women with unexplained infertility. Our future research agenda should also include high-quality multicenter randomized trials assessing the cost-effectiveness of screening and operative hysteroscopy prior to intrauterine insemination or in vitro fertilization.
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Affiliation(s)
- Mohan S Kamath
- Department of Reproductive Medicine, Christian Medical College, Vellore, India
| | - Judith F W Rikken
- Center for Reproductive Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan Bosteels
- Department of Obstetrics and Gynaecology, Imelda Hospital, Bonheiden, Belgium.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, Gent University, Gent, Belgium
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Abdallah KS, Hunt S, Abdullah SA, Mol BWJ, Youssef MA. How and Why to Define Unexplained Infertility? Semin Reprod Med 2020; 38:55-60. [PMID: 33058088 DOI: 10.1055/s-0040-1718709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Unexplained infertility represents up to 30% of all cases of infertility. It is a diagnosis of exclusion, where no cause for infertility may be identified in the investigation of the couple, be it anovulation, fallopian tube blockage, or severe male factor. Unexplained infertility therefore cannot be considered a diagnosis to which a specific treatment is directed, rather that it indicates a failure to reach a diagnosis of the true cause of infertility. In this review, we explore the evidence base and potential limitations of the current routine infertility assessment. We also aim to highlight the importance of considering the prognosis of each individual couple through the process of assessment and propose a reconsidered approach to treatment, targeted to the prognosis rather than the diagnosis. Ultimately, a better understanding of the mechanisms of infertility will reduce the number of couples diagnosed with "unexplained" infertility.
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Affiliation(s)
- Karim S Abdallah
- Department of Obstetrics and Gynecology, Women's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt.,Department of Obstetrics and Gynecology, Monash University, Clayton, Australia
| | - Sarah Hunt
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Department of Obstetrics and Gynecology, Monash Health, Clayton, Australia.,Monash IVF, Richmond, Australia
| | - Sayed A Abdullah
- Department of Obstetrics and Gynecology, Women's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ben W J Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Mohamed A Youssef
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
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Linara-Demakakou E, Bodri D, Wang J, Arian-Schad M, Macklon N, Ahuja K. Cumulative live birth rates following insemination with donor spermatozoa in single women, same-sex couples and heterosexual patients. Reprod Biomed Online 2020; 41:1007-1014. [PMID: 33046376 DOI: 10.1016/j.rbmo.2020.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 11/24/2022]
Abstract
RESEARCH QUESTION What is the cumulative live birth rate (LBR) following donor intrauterine insemination (IUI-D) treatment in a large, retrospective, single-centre cohort of single women, same-sex couples and heterosexual patients? DESIGN Outcomes from 8922 treatments performed in 3333 consecutive women (45% single, 43% from same-sex and 12% from heterosexual couples) were analysed in a 13-year retrospective study from a private, HFEA-regulated UK centre between January 2004 and December 2016. RESULTS A total of 795 live births resulted in an overall delivery rate of 8.9% per cycle, including 24 (3%) twins. Age-specific crude and expected cumulative LBR calculated in four age groups (<35, 35-37, 38-39 and 40-42 years) were 29, 23, 21, 12% and 66, 49, 54, 28%, respectively. A plateau was reached after six cycles, beyond which there were few additional live births. There was no significant difference in cumulative LBR between single women and same-sex couples. In a multivariate analysis, female age (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.90-0.93; P < 0.0001), previous live birth following IUI-D (aOR 2.15; 95% CI 1.69-2.73; P < 0.0001) and mild stimulation (aOR 1.27; 95% CI 1.09-1.48; P = 0.02) had a significant effect on outcome, but relationship status or cycle rank did not. CONCLUSIONS These results indicate there is little benefit performing more than six cycles of IUI-D in all women up to 40 years old, including those from same-sex relationships, while only three attempts seem reasonable in those aged 40-42 years. These results do not reflect current clinical guidelines in the UK. The authors found that consecutive IUI cycles, especially with mild stimulation, were an efficient treatment in all indications.
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Prentice L, Sadler L, Lensen S, Vercoe M, Wilkinson J, Edlin R, Chambers GM, Farquhar CM. IVF and IUI in couples with unexplained infertility (FIIX study): study protocol of a non-inferiority randomized controlled trial. Hum Reprod Open 2020; 2020:hoaa037. [PMID: 32995562 PMCID: PMC7508023 DOI: 10.1093/hropen/hoaa037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/28/2020] [Indexed: 11/16/2022] Open
Abstract
STUDY QUESTIONS In couples with unexplained infertility and a poor prognosis of natural conception, are four cycles of IUI with ovarian stimulation (IUI-OS) non-inferior to one completed cycle of IVF for the outcome of cumulative live birth? Are four cycles of IUI-OS associated with a lower cost per live birth compared to one completed cycle of IVF? Will four cycles of IUI-OS followed by one complete cycle of IVF result in as many live births at lower cost per live birth, than two complete cycles of IVF? Will four cycles of IUI-OS followed by two complete cycles of IVF result in more live births at lower cost per live birth, than two complete cycles of IVF alone? WHAT IS KNOWN ALREADY IUI is widely used in the USA, the UK and Europe as a low cost, less invasive alternative to IVF for couples with unexplained infertility. Although three to six cycles of IUI were comparable to IVF in the three major studies carried out to date, gonadotrophin ovarian stimulation was used in the majority of cases, and this also resulted in a high multiple pregnancy rate in some studies. Ovarian stimulation with clomiphene citrate is known to have lower multiple pregnancy rates. STUDY DESIGN, SIZE, DURATION The FIIX study is a multicentre, open label, parallel, pragmatic non-inferiority randomized controlled trial of 580 couples with unexplained infertility comparing four cycles of IUI-OS with clomiphene citrate and one completed cycle of IVF. Variable block randomization stratified by age and clinic with electronic allocation will be used. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples with poor prognosis for natural conception and who are eligible for publicly funded fertility treatment in six fertility clinics in New Zealand. STUDY FUNDING/COMPETING INTEREST(S) Auckland Medical Research Fund (3718892/1119003), A+ Trust, Auckland District Health Board (A + 8479), Maurice and Phyllis Paykel Trust (3718514). No competing interests. TRIAL REGISTRATION NUMBER ACTRN12619001003167. TRIAL REGISTRATION DATE 15 July 2019 DATE OF FIRST PATIENT’S ENROLMENT 02/08/2019
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Affiliation(s)
- Lucy Prentice
- Fertility Plus, National Women's, Auckland District Health Board, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Lynn Sadler
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand.,Women's Health, National Women's, Auckland District Health Board, Auckland, New Zealand
| | - Sarah Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Melissa Vercoe
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Jack Wilkinson
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Richard Edlin
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Georgina M Chambers
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Cynthia M Farquhar
- Fertility Plus, National Women's, Auckland District Health Board, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Albertini DF, Crosignani P, Dumoulin J, Evers JLH, Leridon H, Mastenbroek S, Painter R, Pinborg A, Somigliana E, Baird DT, Glasier A, La Vecchia C, Albertini DF, Crosignani P, Dumoulin J, Evers JLH, Leridon H, Mastenbroek S, Painter R, Pinborg A, Somigliana E, Baird DT, Glasier A, La Vecchia C. IVF, from the past to the future: the inheritance of the Capri Workshop Group. Hum Reprod Open 2020; 2020:hoaa040. [PMID: 33005753 PMCID: PMC7508025 DOI: 10.1093/hropen/hoaa040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/07/2020] [Indexed: 12/26/2022] Open
Abstract
Today IVF use is booming all over the world and has even started to play a role in demographic analyses. Prognosis-adjusted estimates suggest that up to two-thirds of couples could achieve a live birth. However, the scenario is less exciting in reality. Discontinuation during the cycles is common, and age and ovarian response continue to be crucial in modulating this rate of success. A growing interest is now given to the risk of abuses and in particular to overtreatment and to prescriptions of useless, if not harmful, expensive additional treatments ('add-ons'). A more rational, evidence-based and wise approach is needed. From a scientific perspective, several obscure aspects remain and warrant future investigations. Of particular interest are the neglected role of sperm selection, the potential adult implications of early embryo life in vitro and the issue of sustainability.
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Effect of ejaculatory abstinence period on sperm DNA fragmentation and pregnancy outcome of intrauterine insemination cycles: A prospective randomized study. Arch Gynecol Obstet 2020; 303:269-278. [PMID: 32902676 DOI: 10.1007/s00404-020-05783-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/31/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the effect of the ejaculatory abstinence period on sperm DNA fragmentation and pregnancy rates in IUI cycles. METHODS One hundred and twenty couples with unexplained infertility were prospectively randomized into two groups on the second day of their cycle. In group A, patients had 1-day ejaculatory abstinence period; in group B patients had 3-day ejaculatory abstinence period. Each patient was stimulated with gonadotropins, and IUI was performed. The primary outcome measure was clinical pregnancy and sperm DNA fragmentation rate. RESULTS The pregnancy rate was 17.3% and 18.5% in group A and group B, respectively. No significant difference was found among the groups (p = 0.803). The sperm DNA fragmentation rate for group A (20.71 ± 11.01) and group B (23.78 ± 12.64) were almost similar (p = 0.187). The sperm DNA fragmentation rate was 24.89 ± 12.89 in pregnant couples and 21.71 ± 11.69 in non-pregnant couples (p = 0.288). CONCLUSION Even after a short abstinence period of 1 day, compared to the standard abstinence period of 3 days, pregnancy rates are similar among unexplained infertility couples undergoing ovarian stimulation and IUI. CLINICALTRIALS The study was registered at ClinicalTrials.gov with ID NCT04361292. Date of registration: 27 April 2020. The study was registered retrospectively.
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Evidence-based treatments for couples with unexplained infertility: a guideline. Fertil Steril 2020; 113:305-322. [PMID: 32106976 DOI: 10.1016/j.fertnstert.2019.10.014] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations to practicing physicians and others regarding the effectiveness and safety of therapies for unexplained infertility. METHODS ASRM conducted a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1968 through 2019. The ASRM Practice Committee and a task force of experts used available evidence and informal consensus to develop evidence-based guideline recommendations. MAIN OUTCOME MEASURE(S) Outcomes of interest included: live-birth rate, clinical pregnancy rate, implantation rate, fertilization rate, multiple pregnancy rate, dose of treatment, rate of ovarian hyperstimulation, abortion rate, and ectopic pregnancy rate. RESULT(S) The literature search identified 88 relevant studies to inform the evidence base for this guideline. RECOMMENDATION(S) Evidence-based recommendations were developed for the following treatments for couples with unexplained infertility: natural cycle with intrauterine insemination (IUI); clomiphene citrate with intercourse; aromatase inhibitors with intercourse; gonadotropins with intercourse; clomiphene citrate with IUI; aromatase inhibitors with IUI; combination of clomiphene citrate or letrozole and gonadotropins (low dose and conventional dose) with IUI; low-dose gonadotropins with IUI; conventional-dose gonadotropins with IUI; timing of IUI; and in vitro fertilization and treatment paradigms. CONCLUSION(S) The treatment of unexplained infertility is by necessity empiric. For most couples, the best initial therapy is a course (typically 3 or 4 cycles) of ovarian stimulation with oral medications and intrauterine insemination (OS-IUI) followed by in vitro fertilization for those unsuccessful with OS-IUI treatments.
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Large randomized controlled trials in infertility. Fertil Steril 2020; 113:1093-1099. [DOI: 10.1016/j.fertnstert.2020.04.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 01/12/2023]
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Immediata V, Patrizio P, Parisen Toldin MR, Morenghi E, Ronchetti C, Cirillo F, Baggiani A, Albani E, Levi-Setti PE. Twenty-one year experience with intrauterine inseminations after controlled ovarian stimulation with gonadotropins: maternal age is the only prognostic factor for success. J Assist Reprod Genet 2020; 37:1195-1201. [PMID: 32215826 PMCID: PMC7244676 DOI: 10.1007/s10815-020-01752-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/17/2020] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To report our experience on homologous intrauterine insemination (IUI) with gonadotropin controlled ovarian stimulation (COS) cycles and to examine different variables which could predict IUI success. MATERIALS AND METHODS This is a retrospective analysis of IUIs performed between January 1997 and December 2017. A total of 7359 COS IUI's procedures (2901 couples) were reviewed. Clinical pregnancy, live birth rate and age, body mass index (BMI), smoking habit, duration of infertility, sperm characteristics before and after treatment (total motile count, morphology, and vitality), day 3 FSH, total gonadotropin dose, and number of follicles were assessed by multivariate logistic regression analysis, and data were expressed as odds ratio (OR). RESULTS The mean female age at the time of COS was 35.10 ± 3.93 years. The most common single infertility diagnoses were unexplained infertility (53.55%), mild male factor (19.69%), and anovulation (10.95%). The total progressive motile sperm count (TPMC) was > 1 × 106/ml (mean 1.34 ± 1.08 × 106/ml). The clinical pregnancy rate was 9.38%, and the live birth rate was 7.19% per cycle. Twin pregnancies were 12.17%. Cumulative pregnancy was 21.89% and cumulative live birth rate was 17.58% per couple. Clinical pregnancy and live birth rates were significantly associated with female age [OR 0.97 (95% CI 0.95-0.99) and 0.95 (95% CI 0.93-0.97), respectively] and day 3 FSH [OR 0.91 (95% CI 0.87-0.94) e 0.90 (95% CI 0.87-0.94), respectively]. CONCLUSIONS Clinical pregnancy rate and live birth rates after COS-IUIs were significantly influenced by female age and FSH levels. TRIAL REGISTRATION Clinical trial registration number: NCT03836118.
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Affiliation(s)
- Valentina Immediata
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Pasquale Patrizio
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Yale University, New Haven, CT, USA
| | - Maria Rosaria Parisen Toldin
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Emanuela Morenghi
- Biostatistics Unit, Humanitas Cinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Camilla Ronchetti
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Federico Cirillo
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Annamaria Baggiani
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Elena Albani
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- Department of Gynecology- Division of Gynecology and Reproductive Medicine- Humanitas Fertility Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Yale University, New Haven, CT, USA.
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Col Madendag I, Eraslan Sahin M, Madendag Y, Sahin E, Demir MB, Ozdemir F, Acmaz G, Muderris II. Effect of the anterior uterocervical angle in unexplained infertility: a prospective cohort study. J Int Med Res 2020; 48:300060519893497. [PMID: 31875745 PMCID: PMC7645361 DOI: 10.1177/0300060519893497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/15/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The present study aimed to evaluate an anatomical region, the anterior uterocervical angle (UCA), to determine whether it plays a role in unexplained infertility. METHODS In this prospective, cross-sectional study, unexplained infertile and healthy fertile (controls) women were compared. The longitudinal and transverse axes of the uterine cervix and uterine corpus were measured by transvaginal ultrasonography. The UCA was determined as the angle between two lines. One line was drawn between the internal and the external os, and the other was drawn through the internal cervical os and was parallel to the lower side of the front part of the uterine wall in the internal os. Demographic characteristics and uterocervical ultrasonographic measurements were compared between the two groups. RESULTS Eighty participants, aged from 20 to 35 years, were enrolled (unexplained infertile [n = 30] and healthy fertile women [n = 50)]. The mean lengths of the uterine corpus longitudinal axis, uterine corpus transverse axis, and uterine cervix longitudinal axis were similar between the groups. The mean UCA was significantly higher in healthy fertile women (131.9 ± 22.9 degrees) than in women with unexplained infertility (114.2 ± 17.3 degrees). CONCLUSION The present study shows that a narrow anterior UCA is associated with unexplained infertility.
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Affiliation(s)
- Ilknur Col Madendag
- Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Turkey
| | | | - Yusuf Madendag
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Erdem Sahin
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | | | - Fatma Ozdemir
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Gokhan Acmaz
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Iptisam Ipek Muderris
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
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Bahadur G, Homburg R, Bosmans JE, Huirne JAF, Hinstridge P, Jayaprakasan K, Racich P, Alam R, Karapanos I, Illahibuccus A, Al-Habib A, Jauniaux E. Observational retrospective study of UK national success, risks and costs for 319,105 IVF/ICSI and 30,669 IUI treatment cycles. BMJ Open 2020; 10:e034566. [PMID: 32184314 PMCID: PMC7076239 DOI: 10.1136/bmjopen-2019-034566] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To compare success rates, associated risks and cost-effectiveness between intrauterine insemination (IUI) and in vitro fertilisation (IVF). DESIGN Retrospective observational study. SETTING The UK from 2012 to 2016. PARTICIPANTS Data from Human Fertilisation and Embryology Authority's freedom of information request for 2012-2016 for IVF/ICSI (intracytoplasmic sperm injection)and IUI as practiced in 319 105 IVF/ICSI and 30 669 IUI cycles. Direct-cost calculations for maternal and neonatal expenditure per live birth (LB) was constructed using the cost of multiple birth model, with inflation-adjusted Bank of England index-linked data. A second direct-cost analysis evaluating the incremental cost-effective ratio (ICER) was modelled using the 2016 national mean (baseline) IVF and IUI success rates. OUTCOME MEASURES LB, risks from IVF and IUI, and costs to gain 1 LB. RESULTS This largest comprehensive analysis integrating success, risks and costs at a national level shows IUI is safer and more cost-effective than IVF treatment.IVF LB/cycle success was significantly better than IUI at 26.96% versus 11.49% (p<0.001) but the IUI success is much closer to IVF at 2.35:1, than previously considered. IVF remains a significant source of multiple gestation pregnancy (MGP) compared with IUI (RR (Relative Risk): 1.45 (1.31 to 1.60), p<0.001) as was the rate of twins (RR: 1.58, p<0.001).In 2016, IVF maternal and neonatal cost was £115 082 017 compared with £2 940 196 for IUI and this MGP-related perinatal cost is absorbed by the National Health Services. At baseline tariffs and success rates IUI was £42 558 cheaper than IVF to deliver 1LB with enhanced benefits with small improvements in IUI. Reliable levels of IVF-related MGP, OHSS (ovarian hyperstimulation syndrome), fetal reductions and terminations are revealed. CONCLUSION IUI success rates are much closer to IVF than previously reported, more cost-effective in delivering 1 LB, and associated with lower risk of complications for maternal and neonatal complications. It is prudent to offer IUI before IVF nationally.
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Affiliation(s)
- Gulam Bahadur
- Reproductive Medicine Clinic, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Roy Homburg
- Homerton Fertility Unit, Homerton University Hospital, Homerton Row, London E9 6SR, UK
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Research Institute Reproduction and development, University Medical Centers Amsterdam, location VUmc and AMC, De Boelelaan 1081, 1081 HV Amsterdam, The Netherlands
| | - Peter Hinstridge
- Reproductive Medicine Clinic, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Kanna Jayaprakasan
- University Hospitals of Derby and Burton NHS Trust, Royal Derby Hospital, Derby, Derby, UK
| | - Paul Racich
- Linacre College, Oxford University, St. Cross Road, Oxford, OX13JA, Oxfordshire, UK
| | - Rakib Alam
- Reproductive Medicine Clinic, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Ioannis Karapanos
- Reproductive Medicine Clinic, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Afeeza Illahibuccus
- Reproductive Medicine Clinic, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Ansam Al-Habib
- Reproductive Medicine Clinic, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Eric Jauniaux
- EGA Institute for Womens Health, Faculty of Population Health Science, University College London, London, WC1E 6HX, UK
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Ayeleke RO, Asseler JD, Cohlen BJ, Veltman‐Verhulst SM. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2020; 3:CD001838. [PMID: 32124980 PMCID: PMC7059962 DOI: 10.1002/14651858.cd001838.pub6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intra-uterine insemination (IUI) is a widely-used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rates. OBJECTIVES To determine whether, for couples with unexplained subfertility, the live birth rate is improved following IUI treatment with or without OH compared to timed intercourse (TI) or expectant management with or without OH, or following IUI treatment with OH compared to IUI in a natural cycle. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 17 October 2019, together with reference checking and contact with study authors for missing or unpublished data. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing IUI with TI or expectant management, both in stimulated or natural cycles, or IUI in stimulated cycles with IUI in natural cycles in couples with unexplained subfertility. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, quality assessment and data extraction. Primary review outcomes were live birth rate and multiple pregnancy rate. MAIN RESULTS We include 15 trials with 2068 women. The evidence was of very low to moderate quality. The main limitation was very serious imprecision. IUI in a natural cycle versus timed intercourse or expectant management in a natural cycle It is uncertain whether treatment with IUI in a natural cycle improves live birth rate compared to treatment with expectant management in a natural cycle (odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT, 334 women; low-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle to be 16%, that of IUI in a natural cycle would be between 15% and 34%. It is uncertain whether treatment with IUI in a natural cycle reduces multiple pregnancy rates compared to control (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT, 334 women; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a stimulated cycle It is uncertain whether treatment with IUI in a stimulated cycle improves live birth rates compared to treatment with TI in a stimulated cycle (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs, 208 women; I2 = 72%; low-quality evidence). If we assume the chance of achieving a live birth with TI in a stimulated cycle was 26%, the chance with IUI in a stimulated cycle would be between 23% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle reduces multiple pregnancy rates compared to control (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, 316 women; I2 = 0%; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a natural cycle In couples with a low prediction score of natural conception, treatment with IUI combined with clomiphene citrate or letrozole probably results in a higher live birth rate compared to treatment with expectant management in a natural cycle (OR 4.48, 95% CI 2.00 to 10.01; 1 RCT; 201 women; moderate-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle was 9%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle results in a lower multiple pregnancy rate compared to control (OR 3.01, 95% CI 0.47 to 19.28; 2 RCTs, 454 women; I2 = 0%; low-quality evidence). IUI in a natural cycle versus timed intercourse or expectant management in a stimulated cycle Treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with expectant management in a stimulated cycle (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, 342 women: moderate-quality evidence). If we assume the chance of a live birth with expectant management in a stimulated cycle was 13%, the chance of a live birth with IUI in a natural cycle would be between 14% and 34%. It is uncertain whether treatment with IUI in a natural cycle results in a lower multiple pregnancy rate compared to control (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT, 342 women; low-quality evidence). IUI in a stimulated cycle versus IUI in a natural cycle Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle (OR 2.07, 95% CI 1.22 to 3.50; 4 RCTs, 396 women; I2 = 0%; low-quality evidence). If we assume the chance of a live birth with IUI in a natural cycle was 14%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 36%. It is uncertain whether treatment with IUI in a stimulated cycle results in a higher multiple pregnancy rate compared to control (OR 3.00, 95% CI 0.11 to 78.27; 2 RCTs, 65 women; low-quality evidence). AUTHORS' CONCLUSIONS Due to insufficient data, it is uncertain whether treatment with IUI with or without OH compared to timed intercourse or expectant management with or without OH improves cumulative live birth rates with acceptable multiple pregnancy rates in couples with unexplained subfertility. However, treatment with IUI with OH probably results in a higher cumulative live birth rate compared to expectant management without OH in couples with a low prediction score of natural conception. Similarly, treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with timed intercourse with OH. Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle.
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Affiliation(s)
- Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Joyce Danielle Asseler
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Ben J Cohlen
- Isala Clinics, Location SophiaDepartment of Obstetrics and GynaecologyDr van Heesweg 2Isala ZwolleNetherlands
| | - Susanne M Veltman‐Verhulst
- Department of Reproductive Medicine and GynecologyUniversity Medical Center UtrechtRoom F5.126, PO Box 85500,UtrechtNetherlands3508 GA
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Vargas-Tominaga L, Alarcón F, Vargas A, Bernal G, Medina A, Polo Z. Associated factors to pregnancy in intrauterine insemination. JBRA Assist Reprod 2020; 24:66-69. [PMID: 31693317 PMCID: PMC6993163 DOI: 10.5935/1518-0557.20190060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective To define the factors associated with clinical pregnancy after intrauterine insemination. Methods Retrospective study involving 633 infertility couples, which made up to 1053 cycles of intrauterine insemination. We analyzed the clinical pregnancy rate associated with different factors through the Chi-square test or Fisher's exact test. Results The clinical pregnancy rate was 8.2% per insemination cycle and 13.6% per treated couple. The factors with greater association to clinical pregnancy were to have more than two follicles, to perform the procedure without difficulty, to have 3 years or less of infertility, cervical factor as indication, use of gonadotropins and age less than 38 years. Conclusion Intrauterine insemination requires to be accompanied by proper selection and couples' preparation.
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Affiliation(s)
| | | | - Andrea Vargas
- Centro de Fertilidad y Ginecología del Sur, Cusco, Peru
| | - Gaby Bernal
- Centro de Fertilidad y Ginecología del Sur, Cusco, Peru
| | - Andrea Medina
- Centro de Fertilidad y Ginecología del Sur, Cusco, Peru
| | - Zarela Polo
- Centro de Fertilidad y Ginecología del Sur, Cusco, Peru
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Taş M, Uludag SZ, Aygen ME, Sahin Y. Comparison of oral dydrogesterone and vaginal micronized progesterone for luteal phase support in intrauterine insemination. Gynecol Endocrinol 2020; 36:77-80. [PMID: 31464143 DOI: 10.1080/09513590.2019.1655728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
This study aims to compare the pregnancy outcomes of vaginal micronized progesterone capsules with oral dydrogesterone in subjects with unexplained subfertility who are undergoing IUI in conjunction with ovarian stimulation by using rFSH. A total of 432 patients with unexplained subfertility who underwent IUI in conjunction with ovarian stimulation were enrolled in this retrospective study. Patients were randomized into two groups: (1) dydrogesterone or (2) vaginal micronized progesterone capsules, for luteal phase support. Clinical pregnancy and live birth were the primary outcome measures of the present study. Dydrogesterone was used in 233 participants (54%) and 337 cycles, while 199 participants (46%) and 233 cycles received vaginal micronized progesterone capsule treatment. The proportion of clinical pregnancies (7.4% vs. 10.2%, p = .213), live births (68% vs. 73%, p = .286) were similar in the two groups. Oral dydrogesterone and vaginal micronized progesterone provide similar pregnancy outcomes in terms of clinical pregnancy and live birth rates in women undergoing IUI in conjunction with ovarian stimulation with rFSH. Given the simple and easy administration, lack of safety concerns and better patient tolerability, we suggest that oral dydrogesterone might be preferred for luteal phase support in IUI.
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Affiliation(s)
- Mustafa Taş
- Department of Obstetrics and Gynecology, Acıbadem Mehmet Ali Aydınlar University, Acıbadem Kayseri Hospital, Kayseri, Turkey
| | - Semih Zeki Uludag
- Department of Obstetrics and Gynecology, Memorial Kayseri Hospital, Kayseri, Turkey
| | - Mustafa Ercan Aygen
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
| | - Yılmaz Sahin
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
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50
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Malina A, Głogiewicz M, Piotrowski J. Supportive Social Interactions in Infertility Treatment Decrease Cortisol Levels: Experimental Study Report. Front Psychol 2019; 10:2779. [PMID: 31920828 PMCID: PMC6927458 DOI: 10.3389/fpsyg.2019.02779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/26/2019] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The aim of the research project was to analyze the importance of supportive social interactions in the process of infertility treatment. The acceptance rates of ART (Assisted Reproductive Technology) in Poland are lower than in western European countries and the social stigma of infertility exists. The research project draws attention to the issue of disclosure of fertility problems and the ability to seek support in Polish couples. METHODS An experimental study was conducted with 51 heterosexual couples who qualified for IVF. The participants were randomly divided into an experimental and control group. The first stage of the research procedure, with all the couples, was to extract a saliva (cortisol) sample as a biomarker for stress. In the second stage the control group viewed an informational (non-emotional) video about human embryology. The experimental group took part in a supportive social interaction process. In the supportive social interaction process, a maximum of five couples, were led through a broad general understanding of their IVF experience by an experienced group psychologist. The third stage of the research involved the second extraction of a saliva (cortisol) sample form all participants. In addition, demographic and medical history related to fertility was collected. RESULTS The statistical analysis indicates a significant decrease in the level of stress experienced after the supportive social interaction. The reported differences between the experimental group and the control group indicated a larger decrease of cortisol level for women and men. CONCLUSION In the current study, the hypothesis that taking part in supportive social interaction significantly lowers stress levels (measured via cortisol) of infertile couples (men and women) was supported. Further the project indicates that a supportive social interaction has a beneficial effect on infertile couple's health and well-being. The results of the study clearly point to the benefits of couples involved in infertility treatment to express and share their experience, and in doing so, provides measurable physiological and psychological benefits.
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Affiliation(s)
- Alicja Malina
- Department of Pedagogy and Psychology, Kazimierz Wielki University in Bydgoszcz, Bydgoszcz, Poland
| | - Małgorzata Głogiewicz
- Department of Obstetrics, Gynecology and Gynecological Oncology, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Jakub Piotrowski
- Department of Immunology, Faculty of Biology and Environment Protection, Nicolaus Copernicus University in Toruń, Torun, Poland
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