IUI: review and systematic assessment of the evidence that supports global recommendations

Swim-up versus density gradients for sperm preparation in infertile couples undergoing intrauterine insemination: a randomized clinical trial

STUDY QUESTION

What is the effectiveness of swim-up (SU) and density gradients (DG) for sperm preparation in infertile couples undergoing IUI?

SUMMARY ANSWER

In infertile couples undergoing IUI, SU and DG did not result in statistically significant different live birth rates.

WHAT IS KNOWN ALREADY

SU and DG are the two most commonly used techniques for sperm preparation in infertile couples undergoing IUI. In the latest Cochrane review, given the very low quality of available data, the authors were uncertain whether there was a difference in clinical pregnancy rates between the two techniques. Furthermore, live birth rate was not reported in any trial.

STUDY DESIGN, SIZE, DURATION

This open-label, two-centre, randomized clinical trial was conducted at two IVF centres in Vietnam. A sample size of 912 couples was needed to demonstrate a 5% difference between SU and DG (power 0.80, two-sided alpha 5%, loss to follow-up, and cross-over rate 10%). Randomization was performed using a computer-generated random list, with a variable block size of 2, 4, or 6. Assignment to treatment allocation was done via a web portal.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible couples included those who were ≥18 years of age, where the husbands' sperm concentration, progressive motility (PM) rate, and total PM sperm count before sperm preparation were ≥5 × 106/ml, ≥32%, and >5 × 106 (according to the WHO 2010 criteria), respectively. Couples using frozen semen, or couples where the husband's semen was hyperviscous, were not included. On the day of IUI, participants were randomized (1:1 ratio) to undergo either SU or DG. Sperm preparation was performed within 1 h after ejaculation. IUI was performed once at 36-40 h after hCG trigger. Primary outcome was live birth after the first IUI cycle.

MAIN RESULTS AND THE ROLE OF CHANCE

Between 7 August 2020 and 29 October 2022, we randomized 456 couples to SU and 456 couples to DG. Live birth after the first IUI cycle occurred in 55 (12.1%) couples in the SU group and 71 (15.7%) couples in the DG group (relative risk 0.77; 95% CI 0.56 to 1.07). There were no statistically significant differences between the two groups in terms of other pregnancy outcomes as well as obstetrics and perinatal outcomes.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of the study was its open-label design, due to the nature of the interventions.

WIDER IMPLICATIONS OF THE FINDINGS

In infertile couples undergoing IUI, SU and DG can both be used for sperm preparation. The decision on which to use might depend more on practical factors such as processing time and how easy it is to standardize the method.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by My Duc Hospital, Ho Chi Minh City, Vietnam. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437), reports consultancy, travel support, and research funding from Merck and consultancy for Organon and Norgine, and holds stock from ObsEva. L.N.V. has received grant, speaker, and conference fees from Merck Sharpe and Dohme, and grant, speaker, conference, and scientific board fees from Ferring. T.M.H. has received grant, speaker, and conference fees from Merck Sharpe and Dohme, and grant, speaker, conference, and scientific board fees from Ferring.

TRIAL REGISTRATION NUMBER

NCT04477356.

TRIAL REGISTRATION DATE

6 July 2020.

DATE OF FIRST PATIENT’S ENROLMENT

10 August 2020.

A new accurate model to assess intrauterine insemination success based on clinical parameters: Optimizing fertility treatment

OBJECTIVE

To develop a predictive model for intrauterine insemination (IUI) success based on known clinical parameters.

METHODS

We created an application designed to calculate the probability of IUI success, utilizing data from couples who underwent fertility treatment. The model was developed through a retrospective analysis of clinical and laboratory variables. The main outcome was positive beta human chorionic gonadotrophin (β-hCG) test. The variables included in the model, determined through a multivariate analysis using stepwise regression, encompassed the etiology of infertility, FSH levels in the early proliferative phase, duration of infertility, total sperm count in the ejaculate, and Kruger morphology.

RESULTS

The study included data from 299 couples seeking fertility treatment at the Hospital das Clínicas of the University of São Paulo between 2008 and 2016, involving a total of 355 insemination cycles. All patients underwent IUI treatment for infertility. Various clinical and laboratory variables were examined to build the predictive model for IUI success. The model demonstrated high sensitivity (89.8%), specificity (88.2%), and an area under the ROC curve of 0.946 (95% CI: 0.910-0.982), indicating an overall accuracy of 94.6%. The Hosmer-Lemeshow test yielded a p value of 0.036. This calculator offers healthcare professionals the means to assess the suitability of IUI for individual patients, providing them with tailored guidance.

CONCLUSION

By enhancing the accuracy of IUI success predictions, this model has the potential to optimize the allocation of healthcare resources, alleviate patient stress and disappointment, and ultimately enhance patient outcomes within the field of infertility treatment.

Now is the time to introduce new innovative assisted reproduction methods to implement accessible, affordable, and demonstrably successful advanced infertility services in resource-poor countries

Nearly 200 million people worldwide suffer from infertility. Disparities exist between developed and developing countries due to differences in the availability of infertility care, different reimbursement policies and socio-cultural differences surrounding procreation. In low- and middle-income countries, specialized infertility centres are either scarce or non-existent, mostly in private settings, and accessible only to the fortunate few who can afford them. The success and sustainability of ARTs will depend on our ability to optimize these techniques in terms of availability, affordability, and effectiveness. A low-cost, simplified IVF system has been developed and shown to be safe, cost-effective, and widely applicable to low-resource settings. Combined with inexpensive mild ovarian stimulation protocols, this could become a truly effective means of treating infertility and performing assisted reproduction at affordable prices, but only if such programmes are sincerely desired and supported by all relevant stakeholders. A receptive political, governmental, and clinical community is essential.

Assisted Reproductive Technology, Multiple Births, and Perinatal Outcomes in Taiwan from 2001 to 2020

OBJECTIVE

To investigate the effect of the Assisted Reproduction Act, implemented in 2007 in Taiwan to reduce the number of embryos to transfer, on the trends over time regarding the rate of multiple births, preterm delivery, low birth weight (LBW), and small for gestational age (SGA) among deliveries using assisted reproductive technology (ART).

STUDY DESIGN

From the Birth Reporting Registry and the Assisted Reproduction Registry, we retrieved data of 4 016 530 live birth deliveries between 2001 and 2020; among them 71 000 (1.77%) were after ART. We calculated the rate of multiples and perinatal outcomes per 1000 deliveries annually from 2001 to 2020 for deliveries using and not using ART and computed the population attributable risk. We performed interrupted time series to assess the effect of the intervention, ie, the Assisted Reproduction Act.

RESULTS

The proportion of deliveries following ART was 0.57% in 2001 and increased to 4.03% in 2020. After the intervention, there were decreasing trends over time for rates of multiples (-10.63 per year, P < .001), preterm delivery (-6.74, P = .003), LBW (-9.38, P < .001), and SGA (-4.48, P = .001) among ART deliveries. There was also an immediate decrease right after intervention (-53.45, P = .005) for SGA after ART. The population attributable risk trends before and after intervention were both increasing for all outcomes.

CONCLUSIONS

The Assisted Reproduction Act in Taiwan was associated with a decreasing trend of multiples, preterm delivery, LBW, and SGA over time since 2008 among ART deliveries. In particular, there was an immediate decrease of SGA right after the intervention.

Cumulative live birth rates following intrauterine insemination using donor and husband sperm in different age groups: A cohort study of 10 415 insemination cycles

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.

Assessment of clinical pregnancies in up to eight ovarian stimulation with intrauterine insemination treatment cycles in those unable to proceed with in vitro fertilization

OBJECTIVE

To study the primary objective of clinical pregnancy (CP) rate per ovarian stimulation with intrauterine insemination (OS-IUI) treatment cycle in patients with repetitive cycles up to a maximum of 8 cycles.

DESIGN

Retrospective cohort.

SETTING

Large fertility clinic.

PATIENTS

A total of 37,565 consecutive OS-IUI cycles from 18,509 patients were included in this study.

INTERVENTIONS

Those with anovulatory diagnoses, tubal factor infertility, male factor infertility, using donor sperm, canceled cycles, and those with missing data for either baseline characteristics or outcome were excluded. The CP rate was analyzed using generalized estimating equations and controlled for age, stimulation protocol, and body mass index.

MAIN OUTCOMES MEASURES

Clinical pregnancy was defined as intrauterine gestation with fetal heartbeat visible on ultrasound.

RESULTS

A total of 37,565 consecutive OS-IUI cycles from 2002 through 2019 at a private practice facility were evaluated. All cycles met inclusion criteria and were used in generalized estimating equation modeling. Patients aged <35 years comprised 47.6% of the cohort. After adjustment for confounders, the mean predicted probability of CP for cycles one to 8 was 15.7% per cycle. The mean predicted probability of CP in aggregated data from cycles 2 to 4 was only 1.7% lower compared with cycle 1 as the referent (16.7% vs. 15.0%, 95% confidence interval [CI] 2nd: 0.88 {0.82, 0.95}, 3rd: 0.86 {0.79, 0.93}, 4th: 0.88 {0.79, 0.98}). However, the 15.0% mean predicted probability of CP for the second through the fourth cycle was concordant with the mean for all included cycles (15.7%). The mean predicted probability of CP of cycles 5 to 8 was not significantly different compared with the referent (16.7% vs. 16.1%, 95% CI 5th: 0.97 [0.85, 1.11], 6th: 0.93 [0.79, 1.10], 7th: 1.01 [0.81, 1.26], 8th: 1.01 [0.76, 1.34]). The modeling of consecutive cycles suggested that the adjusted cumulative predicted probability of CP from OS-IUI continues to increase with each of the 8 successive cycles.

CONCLUSION

Clinical pregnancy rates are satisfactory in up to 8 consecutive OS-IUI treatment cycles. These data are useful for counseling, especially in those patients for whom in vitro fertilization is not financially or ethically feasible.

Intrauterine insemination timing models-LH can only take you so far

RESEARCH QUESTION

Can an optimal LH threshold algorithm accurately predict timing of ovulation for natural cycle-intrauterine insemination (NC-IUI)?

DESIGN

A retrospective cohort study (2018-2022) including 2467 natural cycles. Ovulation timing for these cycles was determined using a previously developed AI model. Two LH thresholds, low and high, were determined in the LH algorithm. Being below the low threshold meant that ovulation is likely to occur in ≥ 4 days, suggesting another daily blood test. Between the two thresholds meant that ovulation was likely in 2-3 days, suggesting IUI the next day. Above the high threshold meant that ovulation will likely occur tomorrow, suggesting performing IUI on the same day.

RESULTS

The optimal LH model with a high threshold of 40 mIU/ml and a low threshold of 11 mIU/ml succeeded in correctly predicting timing for IUI (day - 1, - 2 relative to ovulation) in 75.4% (95%CI 75.3-75.4). In 23.1% (95%CI 23.0-23.2), the algorithm predicted "error," suggesting performing insemination when in fact it would have been performed on a non-optimal day (0 or - 3). A previously described 3-hormone-based (LH, estradiol, progesterone) AI model performed significantly better in all parameters (93.6% success rate, 4.3 "error" rate).

CONCLUSIONS

An LH threshold model, representing common practice, evaluating all possible high and low LH threshold combinations, was successful in accurately scheduling timing for IUI in only 75% of cases. Integrating all three hormones as performed in the AI model may have an advantage in accurately predicting the optimal time for IUI, over the use of LH only.

Intrauterine insemination: prognostic factors

OBJECTIVE

To evaluate the impact of possible maternal and paternal prognostic factors and ovarian stimulation protocols on clinical pregnancy and live birth rates in intrauterine insemination (IUI) cycles.

METHODS

Retrospective observational study of 341 IUI cycles performed from January 2016 to November 2020 at the Assisted Reproduction Service of the Clinics Hospital of the Ribeirão Preto Medical School, University of São Paulo. Clinical pregnancy and live birth rates and their potential prognostic factors were evaluated. Wilcoxon's non-parametric test was used to compare quantitative variables, and the chi-square test to compare qualitative variables, adopting a significance level of p<0.05. A logistic regression model was performed to verify which exploratory variables are predictive factors for pregnancy outcome.

RESULTS

The ovulation induction protocol using gonadotropins plus letrozole (p=0.0097; OR 4.3286, CI 1.3040 - 14.3684) and post-capacitation progressive sperm ≥ 5million/mL (p=0.0253) showed a statistically significant correlation with the live birth rate. Female and male age, etiology of infertility, obesity, multifollicular growth, endometrial thickness ≥ 7 mm, and time between human chorionic gonadotropin administration and IUI performance were not associated with the primary outcomes. In the group of patients with ideal characteristics (women aged< 40 years, BMI < 30 kg/m2, antral follicle count ≥ 5, partner aged< 45 years, and post-capacitation semen with progressive spermatozoa ≥ 5 million/mL), the rate of clinical pregnancy was 14.8%, while that of live birth, 9.9%.

CONCLUSIONS

In this study, the ovulation induction protocol with gonadotropins plus letrozole and post-capacitation progressive sperm ≥ 5 million/mL were the only variables that significantly correlated with intrauterine insemination success.

A prospective proof-of-concept trial on the effect of personalized dosages of follitropin delta in intrauterine insemination

RESEARCH QUESTION

What is the efficacy and safety of individualized follitropin delta dosing for ovarian stimulation in intrauterine insemination (IUI)?

DESIGN

This single-centre, prospective, open-label, single-cohort study involving 106 patients established an original dosing regimen based on body weight and anti-Müllerian hormone (AMH) concentrations, with adjustments based on the ovarian response from the previous IUI cycle. Each participant was enrolled in a maximum of three IUI cycles.

RESULTS

Mean age was 34.5 ± 4.5 years, mean weight 69.2 ± 11.2 kg, mean AMH 15.7 ± 8.6 pmol/l, mean FSH 6.3 ± 2.6 IU/l and mean antral follicle count 16.4 ± 8.2. The percentage of patients who produced more than three mature follicles was 1.9%, 0% and 1.5%, respectively, for the three IUI cycles. The percentage of patients with two or three mature follicles was 34.0%, 36.9% and 47.1% for the three IUI cycles. The clinical pregnancy rate per IUI cycle was 17.9%, 14.3% and 17.6% for the three cycles, with a cumulative clinical pregnancy rate of 40.6%. Out of 258 cycles, 43 (16.7%) resulted in clinical pregnancy, with six of those resulting in multiple pregnancies (14.0%). Two resulted in spontaneous reduction within the first trimester and four resulted in live twin births, representing only 1.6% of the total cycles.

CONCLUSIONS

This study is the first to utilize follitropin delta for stimulation in IUI. It demonstrates that individualized dosing is both effective and safe, resulting in satisfactory cumulative pregnancy rates and an acceptable multiple pregnancy rate, thus achieving the primary objectives of the research.

Analysis of factors associated with IUI pregnancy outcomes in elderly and young patients

OBJECTIVE

The objective of this study was to investigate the correlation between various factors and the clinical outcomes of Intrauterine Insemination (IUI) in both young and aged patients, aiming to provide a theoretical basis for clinical consultations.

METHODS

This retrospective analysis examined a total of 4,221 IUI cycles conducted at the Reproductive Center of Changzhou Maternal and Child Health Hospital between January 2016 and December 2020. The patients were categorized into two groups based on age: the elder group (≥ 35 years) and the young group (< 35 years).

RESULTS

The findings of this study revealed a significant association between woman's age and BMI with pregnancy outcomes (0.93, 95% CI: 0.89-0.97) (1.04, 95% CI: 1.01-1.06). Moreover, in young women, both age and Body Mass Index (BMI)were found to be related to pregnancy outcomes (0.97, 95% CI: 0.89-0.97) (1.08, 95% CI: 1.01-1.06). Additionally, BMI and the number of cycles in aged IUI patients were found to be associated with pregnancy outcomes. The pregnancy rate in the second cycle was approximately 1.9 times higher than that in the first cycle (1.9, 95% CI: 0.97-3.77), and in the third cycle, it was approximately 3 times higher than that in the first cycle (3.04, 95% CI: 1.43-6.42).

CONCLUSIONS

In conclusion, there is an association between woman's age and BMI and the clinical outcomes of IUI. However, the number of cycles did not affect the pregnancy outcomes in young women. Conversely, in elder women, the number of cycles was found to be related to the IUI pregnancy outcomes, with significantly higher pregnancy rates observed in the second and third cycles compared to the first cycle.

Effect of small follicles on clinical pregnancy and multiple pregnancy rates in intrauterine insemination: a cohort study

STUDY QUESTION

What is the effect of small follicles on clinical pregnancy and multiple pregnancy rates in women undergoing IUI with ovarian stimulation (IUI-OS)?

SUMMARY ANSWER

The presence of ≥2 small follicles with a diameter of 10-12 or 12-14 mm was associated with an increased chance of clinical pregnancy and the presence of any 12-14 mm or larger follicles, but not smaller follicles, was statistically significantly associated with an increased risk for multiple pregnancy.

WHAT IS KNOWN ALREADY

IUI-OS is widely used as the first-line treatment for unexplained or mild male factor infertility. However, IUI is associated with the risk of multiple pregnancy. While the positive association between the number of follicles ≥14 mm and the chance of pregnancy and the risk of multiple pregnancy is known, the impact of smaller follicles is uncertain.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study that included women undergoing IUI cycles from January 2007 to May 2021 in one assisted reproduction center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the impact of the number and size of follicles on trigger day on clinical pregnancy and multiple pregnancy rates. Generalized estimation equation regression models were used to compute unadjusted and adjusted odds ratios and 95% CI in all women and only women who achieved clinical pregnancy separately. The chance of clinical pregnancy and multiple pregnancy for different numbers of small follicles in cycles with one >18-mm follicle was calculated using marginal effects estimate.

MAIN RESULTS AND THE ROLE OF CHANCE

This cohort included 12 933 IUI cycles in 7504 women. The overall clinical pregnancy rate was 16.1% (2081/12 933), with a multiple pregnancy rate of 10.5% (218/2081). In the adjusted analysis, the chance of clinical pregnancy increased significantly with the increase in the number of follicles with the diameter of 14-16, 16-18, and 18-20 mm. As for 10-12 mm [adjusted odds ratio (aOR) 1.22, 95% CI 1.02-1.46] and 12-14 mm (aOR 1.29, 95% CI 1.07-1.56) follicles, only groups with ≥2 follicles of those sizes showed significantly increased chance of clinical pregnancy. In cycles that led to pregnancy, follicles with the diameter of 12-14 mm were associated with an increased risk of multiple pregnancy (aOR 1.73, 95% CI 1.19-2.53 for one such follicle; aOR 2.27, 95% CI 1.44-3.56 for ≥2 such follicles), while 10- to 12-mm follicles were not significantly associated with multiple pregnancy (aOR 1.18, 95% CI 0.72-1.95 for ≥2 such follicles). The associations of multiple pregnancy were similar when including all cycles.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective observational study from a single center. The records of follicle diameter in our center were of a 2-mm interval which limited our ability to analyze the size of follicle as a continuous variable. Also, the number of cycles with a high number of small follicles was still limited which impeded more detailed analysis on the ≥2 follicles subgroup. Similarly, the value of some parts of the marginal probability estimation for multiple pregnancy versus pregnancy according to size and number of follicles was also limited by the low sample size of certain combinations.

WIDER IMPLICATIONS OF THE FINDINGS

Follicles larger than 10 mm, especially those ≥12 mm, may need to be clearly recorded during transvaginal ultrasound surveillance and their potential effects on both pregnancy and multiple pregnancy can be discussed with couples undergoing IUI.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (Grant numbers 82201912, 82371651, and 82071615) and Shanghai Sailing Program (21YF1423200). B.W.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Ambient ozone and ovarian reserve in Chinese women of reproductive age: Identifying susceptible exposure windows

Little is known about the association of ambient ozone with ovarian reserve. Based on a retrospective cohort study of 6008 women who attended a fertility center in Hubei, China, during 2018-2021, we estimated ozone exposure levels by calculating averages during the development of follicles (2-month [W1], 4-month [W2], 6-month [W3]) and 1-year before measurement (W4) according to Tracking Air Pollution in China database. We used multivariate logistic regression and linear regression models to investigate association of ozone exposure with anti-müllerian hormone (AMH), the preferred indicator of ovarian reserve. Each 10 μg/m3 increases in ozone were associated with 2.34% (0.68%, 3.97%), 2.08% (0.10%, 4.01%), 4.20% (1.67%, 6.67%), and 8.91% (5.79%, 11.93%) decreased AMH levels during W1-W4; AMH levels decreased by 15.85%, 11.90%, 16.92% in the fourth quartile during W1, W3, and W4 when comparing the extreme quartile, with significant exposure-response relationships during W4 (P < 0.05). Ozone exposure during W1 was positively associated with low AMH. Additionally, we detected significant effect modification by age, body mass index, and temperature in ozone-associated decreased AMH levels. Our findings highlight the potential adverse impact of ozone pollution on female ovarian reserve, especially during the secondary to small antral follicle stage and 1-year before measurement.

Impact of current and previous sperm findings on outcomes of intrauterine insemination

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.

Is There Any Effect of Change in Pre-Wash and Post-Wash Semen Parameters on the Success of Intrauterine Insemination?

(1) Background: We aimed to investigate the effect of change in pre-wash and post-wash semen parameters on intrauterine insemination (IUI) success in a homogenous study group. (2) Methods: IUI cycles conducted at an infertility clinic were included in this study. Patient records were examined retrospectively. Δ sperm count (per mL) was calculated as [pre-wash sperm count (per mL)-post-wash sperm count (per mL)]. Δ Total progressive motile sperm count (TPMSC) was also calculated as (post-wash TPMSC-pre-wash TPMSC). (3) Results: No statistically significant difference was detected in terms of Δ sperm count (p = 0.38), and Δ TPMSC (p = 0.76) regarding the clinical pregnancy rate (CPR). There was no statistically significant difference between CPR (+) and CPR (-) groups in terms of post-wash sperm count, TPMSC, TPMSC ≥ 10 × 10⁶, TPMSC ≥ 5 × 10⁶ (p = 0.65, p = 0.79, p = 0.49, p = 0.49, respectively). The live birth rate (LBR) showed no statistically significant differences except for a pre-wash TPMSC ≥ 10 × 10⁶ (p = 0.02). Through the performed ROC analysis, no statistically significant cutoff value could be set for the pre-wash TPMSC. (4) Conclusions: There is only a pre-wash TPMSC ≥ 10 × 10⁶ that showed a significant role in the success of IUI, even when considering all other pre-wash and post-wash semen parameters. Δ sperm count and Δ are not useful markers for IUI success.

Estimation of follicular growth-widely used, seldom studied

We assessed whether estimation of follicular growth, rather than actual measurement of follicular size on the day of hCG trigger, affected pregnancy rates in intrauterine insemination (IUI) cycles. Patient and cycle characteristics were extracted from an existing database. Comparisons were made between the pregnant (defined as a positive beta hCG) and non-pregnant groups for the following variables: patient's age, number of previous IUI cycles, type of ovarian stimulation, endometrial thickness, number of follicles measuring 14 mm and above, pre and post wash sperm parameters, cycle day when IUI was done and number of days between last ultrasound scan and ovulation trigger. A total of 7302 cycles were included in the final analysis. In 4055 cycles (55.5%) the hCG trigger was on the day of the last ultrasound, in 2285 cycles (31.3%) the hCG trigger was 1 day after the last ultrasound, in 850 (11.6%) it was 2 days after the last ultrasound and in 112 (1.5%) it was 3 or more days after the last ultrasound. Sperm parameters, younger maternal age, and the number of follicles above 14 mm were all associated with pregnancy. No association was found between positive pregnancy test rates and the time from last ultrasound to hCG trigger. Planning IUI based on the estimation of follicular growth 1-4 days before trigger, does not affect pregnancy rates.

Sperm DNA Fragmentation after Cryopreservation and Sperm Selection Has No Implications for Clinical Pregnancies and Live Births after Intrauterine Insemination with Donor Sperm

Intrauterine insemination with donor sperm (IUI-D) requires multiple in vitro manipulations such as sperm selection and cryopreservation during which spermatozoa may be exposed to oxidative stress (OS) and other insults that may produce potential damage including sperm DNA fragmentation (SDF). High levels of SDF, referring to damage or breaks in the genetic material of sperm cells, are linked to an increased risk of reproductive failure. This retrospective, observational study set out to evaluate whether SDF assessment could predict clinical outcome in an IUI-D program, where sperm donors are selected on strict conventional semen parameters. A total of 18 donors and 106 recipients were matched for IUI-D. Out of 429 cycles, 100 (23.3%) resulted in clinical pregnancy. We counted 78 live births (18.2% of cycles), while 20 pregnancies ended in miscarriage (4.7% of cycles), 1 in extra-uterine pregnancy and 1 in stillbirth. Female age significantly influenced clinical pregnancy and miscarriage rates. SDF increased after cryopreservation (26.3 ± 14.5%; p < 0.001) and more so after post-thaw density gradient (34.9 ± 22.1%; p = 0.04) without affecting clinical pregnancy (OR [95% CI] 1.01 [0.99; 1.02]; p = 0.27), live birth (1.00 [0.99; 1.02]; p = 0.72) and miscarriage rates (1.02 [1.00; 1.05]; p = 0.08). The implications of our findings extend to a better selection of sperm donors and a better sperm preparation technique tailored to the donor semen's properties in order to maximize the chances of a favorable treatment outcome.

Artificial intelligence in the service of intrauterine insemination and timed intercourse in spontaneous cycles

OBJECTIVE

To develop a machine learning model designed to predict the time of ovulation and optimal fertilization window for performing intrauterine insemination or timed intercourse (TI) in natural cycles.

DESIGN

A retrospective cohort study.

SETTING

A large in vitro fertilization unit.

PATIENT(S)

Patients who underwent 2,467 natural cycle-frozen embryo transfer cycles between 2018 and 2022.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prediction accuracy of the optimal day for performing insemination or TI.

RESULT(S)

The data set was split into a training set including 1,864 cycles and 2 test sets. In the test sets, ovulation was determined according to either expert opinion, with 2 independent fertility experts determining ovulation day ("expert") (496 cycles), or according to the disappearance of the leading follicle between 2 consecutive days' ultrasound examinations ("certain ovulation") (107 cycles). Two algorithms were trained: an NGBoost machine learning model estimating the probability of ovulation occurring on each cycle day and a treatment management algorithm using the learning model to determine an optimal insemination day or whether another blood test should be performed. The estradiol progesterone and luteinizing hormone levels on the last test performed were the most influential features used by the model. The mean numbers of tests were 2.78 and 2.85 for the "certain ovulation" and "expert" test sets, respectively. In the "expert" set, the algorithm correctly predicted ovulation and suggested day 1 or 2 for performing insemination in 92.9% of the cases. In 2.9%, the algorithm predicted a "miss," meaning that the last test day was already ovulation day or beyond, suggesting avoiding performing insemination. In 4.2%, the algorithm predicted an "error," suggesting performing insemination when in fact it would have been performed on a nonoptimal day (0 or -3). The "certain ovulation" set had similar results.

CONCLUSION(S)

To our knowledge, this is the first study to implement a machine learning model, on the basis of the blood tests only, for scheduling insemination or TI with high accuracy, attributed to the capability of the algorithm to integrate multiple factors and not rely solely on the luteinizing hormone surge. Introducing the capabilities of the model may improve the accuracy and efficiency of ovulation prediction and increase the chance of conception.

CLINICAL TRIAL REGISTRATION NUMBER

HMC-0008-21.

Should IUI replace IVF as first-line treatment for unexplained infertility? A literature review

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.

Alternatives to in vitro fertilization

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.

Fine-tuning the dose of recombinant human follicle-stimulating hormone alfa to individualize treatment in ovulation induction and ovarian stimulation cycles: a real-world database analysis

Introduction

Fine-tuning of injectable gonadotropin doses during ovulation induction (OI) or ovarian stimulation (OS) treatment cycles with the aim of using doses low enough to minimize the risk of excessive ovarian response while maintaining optimal efficacy may be facilitated by using an adjustable-dose pen injector. We examined the incidence and magnitude of individualized gonadotropin dose adjustments made during cycles of OI or OS, followed by either timed intercourse or intrauterine insemination, with or without oral medications, and assessed the relationship between patient characteristics and dosing changes using real-world evidence.

Methods

This was an observational, retrospective cohort study using electronic medical records from a large US database of fertility centers. Data from patients who had undergone a first recombinant human follicle stimulating hormone alfa (r-hFSH-alfa/follitropin alfa) treated OI/OS cycle followed by timed intercourse or intrauterine insemination between 2015 and 2016 were included. Percentages of OI/OS cycles involving r-hFSH-alfa dose adjustments (in increments of ±12.5 IU or greater) with or without oral medications (clomiphene citrate or letrozole) were analyzed.

Results

Of 2,832 OI/OS cycles involving r-hFSH-alfa administration, 74.6% included combination treatment with orals; 25.4% involved r-hFSH-alfa alone. As expected, the starting dose of r-hFSH-alfa was lower for cycles that used r-hFSH-alfa with orals than r-hFSH-alfa only cycles (mean [SD]: 74.2 [39.31] vs 139.3 [115.10] IU). Dose changes occurred in 13.7% of r-hFSH-alfa with orals versus 43.9% of r-hFSH-alfa only cycles. Dose adjustment magnitudes ranged from ±12.5 IU to ±450 IU. The smallest adjustment magnitudes (±12.5 IU and ±25 IU) were used frequently and more often for dose increases than for dose decreases. For r-hFSH-alfa with orals and r-hFSH-alfa only cycles, the smallest adjustments were used in 53.5% and 64.5% of cycles with dose increases and in 35.7% and 46.8% of cycles with dose decreases, respectively.

Discussion

In OI/OS cycles followed by timed intercourse or intrauterine insemination, r-hFSH-alfa dose adjustments were frequent. In cycles that included orals, r-hFSH-alfa starting doses were lower and dose changes were fewer than with r-hFSH-alfa alone. Smaller dose adjustments facilitate individualized treatment with the goal of reducing the risks of multiple gestation, cycle cancellation, and ovarian hyperstimulation syndrome.

Pregnancy among Women Undergoing Intrauterine Insemination in a Centre

Introduction

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

Methods

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

Results

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

Conclusions

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

Keywords

artificial insemination; Nepal; pregnancy rate.

Intrauterine Insemination After Human Chorionic Gonadotropin Trigger or Luteinizing Hormone Surge: A Meta-analysis

OBJECTIVE

To assess the odds of pregnancy after intrauterine insemination (IUI) timed by ultrasound monitoring and human chorionic gonadotropin (hCG) administration compared with monitoring luteinizing hormone (LH) levels.

DATA SOURCES

We searched PubMed (MEDLINE), EMBASE (Elsevier), Scopus (Elsevier), Web of Science (Clarivate Analytics), ClinicalTrials.gov (National Institutes of Health), and the Cochrane Library (Wiley) from the inception until October 1, 2022. No language limitations were applied.

METHODS OF STUDY SELECTION

After deduplication, 3,607 unique citations were subjected to blinded independent review by three investigators. Thirteen studies (five retrospective cohort, four cross-sectional, two randomized controlled trials, and two randomized crossover studies) that enrolled women undergoing natural cycle, oral medication (clomid or letrozole), or both for IUI were included in the final random-effects model meta-analysis. Methodologic quality of included studies was assessed with the Downs and Black checklist.

TABULATION, INTEGRATION, AND RESULTS

Data extraction was compiled by two authors, including publication information, hCG and LH monitoring guidelines, and pregnancy outcomes. No significant difference in odds of pregnancy between hCG administration and endogenous LH monitoring was observed (odds ratio [OR] 0.92, 95% CI 0.69-1.22, P=.53). Subgroup analysis of the five studies that included natural cycle IUI outcomes also showed no significant difference in odds of pregnancy between the two methods (OR 0.88, 95% CI 0.46-1.69, P=.61). Finally, a subgroup analysis of 10 studies that included women who underwent ovarian stimulation with oral medications (clomid or letrozole) did not demonstrate a difference in odds of pregnancy between ultrasonography with hCG trigger and LH-timed IUI (OR 0.88, 95% CI 0.66-1.16, P=.32). Statistically significant heterogeneity was noted between studies.

CONCLUSION

This meta-analysis showed no difference between pregnancy outcomes between at-home LH monitoring and timed IUI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021230520.

Bloodstream infections and antibiotic resistance patterns: a six-year surveillance study from southern Italy

Bloodstream infections (BSI) are associated with high morbidity and mortality. This study aimed to describe the epidemiology of BSI and antimicrobial resistance patterns amongst its common bacterial causes. We conducted a retrospective record review of blood culture results of patients hospitalized with BSI at University Hospital 'L. Vanvitelli' from 2016 to 2021. For each patient records were obtained from the database using microbiological information. Gram-positive bacteria were the most predominant pathogens followed by Gram-negative bacteria. Among all isolates, bacterial pathogens most frequently identified included coagulase-negative Staphylococci (CoNS), Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and enterococci. We noted a general decrease in antimicrobial resistance amongst BSI pathogens in the latter years of the study. High levels of macrolide and aminoglycoside resistance amongst CoNS were reported. Carbapenem resistance amongst E. coli was barely reported, while resistance rates amongst K. pneumoniae declined considerably between 2018 and 2021. The prevalence of methicillin-resistant S. aureus decreased during the study period while that of methicillin-resistant CoNS remained relatively high throughout. The prevalence of extended spectrum ß-lactamase - producing E. coli increased considerably between 2016 and 2018 but showed a slight decrease thereafter. Conversely, there was a general decline in the resistant rates of extended spectrum ß-lactamase - producing K. pneumoniae between 2016 and 2018 with a similar trend being noted for carbapenem resistance in K. pneumoniae. Continuously monitoring the changes in the trends in BSI microbiological profiles, including pathogen profiles and the associated antibiotic resistance patterns, can help diagnostic approaches, treatment strategies and prevention programs.

Optimizing intrauterine insemination and spontaneous conception in women with unilateral hydrosalpinx or tubal pathology: A systematic review and narrative synthesis

BACKGROUND

Tubal surgery's role in infertile women with unilateral tubal pathology (e.g. hydrosalpinx, tubal occlusion) who desire spontaneous or intrauterine insemination (IUI) conception where in-vitro fertilisation is infeasible remains unclear.

OBJECTIVE

To conduct a systematic review on fertility outcomes in women with unilateral tubal pathology desiring to conceive spontaneously or via IUI and to find guidance to support therapeutic tubal procedures to help these women conceive.

SEARCH STRATEGY

Using a protocol registered on PROSPERO (ID CRD42021248720), we searched PubMed, EMBASE, CINAHL, and Cochrane Library from inception until June 2022. Bibliographies were reviewed to identify other relevant articles.

DATA COLLECTION AND ANALYSIS

Two authors independently selected and extracted data. Disagreements were resolved by a third author. Studies presenting fertility outcome data in infertile women with unilateral tubal pathologies desiring spontaneous or IUI conception were included. Methodologic quality was assessed using a modified Newcastle Ottawa Scale for observational studies and the Institute of Health Economics Quality Appraisal Checklist for case series. Primary outcomes collated included cumulative pregnancy rate (CPR) and pregnancy rate per cycle (PR/cycle). Secondary outcomes such as ectopic pregnancy, birth outcomes, and pelvic inflammatory disease were collated. These were stratified by the types of unilateral tubal occlusion (UTO) i.e. hydrosalpinx, proximal tubal occlusion (PTO), or distal tubal occlusion (DTO) MAIN RESULTS: Two studies reported spontaneous or IUI pregnancies after treatment of unilateral hydrosalpinx with one reporting a pregnancy rate of 88% within 5.6 months on average. Thirteen studies compared IUI outcomes between women with UTO vs unexplained infertility and bilateral tubal patency (controls). Almost all were retrospective cohort studies and identified UTO by hysterosalpingography. In general, PTOs had no difference in PR/cycle and CPR compared to controls and significantly higher PR/cycle to DTOs. Women with DTOs had minimal incremental CPR benefit with each additional IUI cycle.

CONCLUSIONS

Therapeutic salpingectomy or tubal occlusion improve IUI or spontaneous conception in women with hydrosalpinx, although more prospective studies are needed. While significant study heterogeneity hampered assessment of fertility outcomes, overall, infertile women with PTOs had similar IUI pregnancy outcomes to those with bilateral tubal patency while DTOs had inferior PR/cycle. This review highlights significant deficiencies in the evidence guiding management for this group of patients.

An Algorithm to Predict the Lack of Pregnancy after Intrauterine Insemination in Infertile Patients

Increasing intrauterine insemination (IUI) success rates is essential to improve the quality of care for infertile couples. Additionally, straight referral of couples with less probability of achieving a pregnancy through IUI to more complex methods such as in vitro fertilization is important to reduce costs and the time to pregnancy. The aim of the present study is to prospectively evaluate the threshold values for different parameters related to success in intrauterine insemination in order to provide better reproductive counseling to infertile couples, moreover, to generate an algorithm based on male and female parameters to predict whether the couple is suitable for achieving pregnancy using IUI. For that, one hundred ninety-seven infertile couples undergoing 409 consecutive cycles of intrauterine insemination during a two-year period were included. The first year served as a definition of the parameters and thresholds related to pregnancy achievement, while the second year was used to validate the consistency of these parameters. Subsequently, those parameters that remained consistent throughout two years were included in a generalized estimating equation model (GEE) to determine their significance in predicting pregnancy achievement. Parameters significantly associated with the lack of pregnancy through IUI and included in the GEE were (p < 0.05): (i) male age > 41 years; (ii) ejaculate sperm count < 51.79 x 106 sperm; (iii) swim-up alkaline Comet > 59%; (iv) female body mass index > 45 kg/m2; (v) duration of infertility (>84 months), and (vi) basal LH levels > 27.28 mUI/mL. The application of these limits could provide a pregnancy prognosis to couples before undergoing intrauterine insemination, therefore avoiding it in couples with low chances of success. The retrospective application of these parameters to the same cohort of patients would have increased the pregnancy rate by up to 30%.

The need for longitudinal data on the value of fertility treatment for infertile patients' quality of life: A review and pilot study

Infertility threatens the life goal of parenthood and, hence, quality of life (QoL) of (wo)men, but the fertility clinic trajectory might be burdensome. This review of longitudinal studies and pilot longitudinal study examines the impact of the pre-in vitro fertilization (IVF) fertility clinic trajectory on patient-reported outcome measures (PROMs) for emotional well-being, including QoL. A publication found that the diagnostic workup decreases men's infertility-specific distress while publications disagree whether it decreases (wo)men's anxious and depressive reactions. Intrauterine insemination (IUI) was found to increase (wo)men's depressive reactions. Publications on infertility-specific, health-related, and overall QoL were missing. The pilot indicated that (wo)men's overall QoL is not affected by the diagnostic workup but is decreased by the time of the third IUI. Longitudinal studies on the impact of starting the fertility clinic trajectory on PROMs are needed as they are essential for patient-centered clinical decision-making and patient-centered policy-level decision-making.

Factors Influencing the Pregnancy Outcome of Intrauterine Insemination and Follow-up Treatment

Background

Many factors were reported associated with the pregnancy rate of intrauterine insemination (IUI), which played key role is still debated.

Aims

The aim of this study was to explore related clinical pregnancy outcome factor in IUI cycles of non-male factor.

Settings and Design

The clinical data of 1232 IUI cycles in 690 couples experiencing infertility who attended the Reproductive Center of Jinling Hospital between July 2015 and November 2021 were retrospectively analysed.

Materials and Methods

Female and male age, body mass index (BMI), anti-Müllerian hormone (AMH), male semen parameters before and after wash, endometrial thickness (EMT), artificial insemination timing and ovarian stimulation (OS) protocols were compared between the pregnant group and the non-pregnant group in order to explore any correlation.

Statistical Analysis Used

Continuous variables were analysed using independent-samples t-test, and Chi-square test was used for comparison of measurement data between the two groups. P <0.05 was considered statistical significance.

Results

There were statistically significant differences in female AMH, EMT and duration of OS between the two groups. The AMH was higher in the pregnant group than in the non-pregnant group (P < 0.01), the stimulated days was significantly longer (P < 0.05) and EMT was significantly greater (P < 0.01) in the pregnant group than in the non-pregnant group. Further analysis showed that when patients with IUI had the following conditions: AMH > 4.5 ng/ml, EMT between 8 and 12 mm and letrozole + human menopausal gonadotropin stimulation with higher clinical pregnancy. However, there were no differences between the pregnant group and the non-pregnant group amongst the female and male age, BMI, hormones on baseline and day of human chorionic gonadotrophin, number of ovulated oocytes, sperm parameters before and after wash, treatment protocols and the timing of IUI (P > 0.05). Furthermore, there were 240 couples who not pregnant received one or more cycles of in vitro fertilisation/intracytoplasmic sperm injection/ pre-implantation genetic technology treatment, and another 182 couples forgo follow-up treatment.

Conclusion

The results of the present study demonstrate that the clinical IUI pregnancy rate is correlated with the factors of female AMH, EMT and OS protocol; more studies and samples are necessary to evaluate whether other factors affect pregnancy rate.

Is There a Relationship between Sperm DNA Fragmentation and Intra-Uterine Insemination Outcome in Couples with Unexplained or Mild Male Infertility? Results from the ID-Trial

BACKGROUND

Sperm DNA fragmentation has been proposed as a candidate test for the assessment of sperm function on the premise that damage to the sperm chromatin is associated with a detrimental reproductive outcome. The objective of our study was to investigate whether sperm DNA fragmentation testing has a prognostic value, and thus can play a pivotal role in selecting future patients for intra-uterine insemination (IUI) therapy.

METHODS

This was a prospective cohort study conducted in a University Hospital setting. SDF was measured through TUNEL assay on the fresh semen sample presented at diagnosis and at insemination in couples with idiopathic/mild male infertility undergoing natural cycle IUI treatment. The generalized estimating equation (GEE)-model and multivariable model were used to analyze the probability of live birth and clinical pregnancy, respectively. ROC analysis was carried out to determine an SDF cut-off.

RESULTS

There was an inverse relationship between SDF in the ejaculate of the diagnostic semen sample and CP (p = 0.02; OR 0.94 95% CI (0.90, 0.989)) as well as LB (p = 0.04; OR 0.95 95% CI (0.90, 0.9985)). No significant association was found between SDF after gradient and IUI outcome in the diagnostic sample nor between SDF (ejaculate/after gradient) in the IUI samples. The ROC analysis proposed a cutoff of 17.5% as the best compromise between sensitivity and specificity in the diagnostic SDF for live birth; however, the test diagnostics are low, with an AUC of 0.576.

CONCLUSIONS

Overall, this study strengthens the hypothesis of an inverse relationship between SDF and CP/LB. Furthermore, SDF taken together with other clinical characteristics might provide more insight into male reproductive potential and predicting IUI outcome. Couples with SDF ≥ 17.5% in the diagnostic semen sample did not reach live birth. Further research is necessary to establish the diagnostic and prognostic potential of SDF as an add-on test.

Low BMI is associated with poor IUI outcomes: a retrospective study in 13,745 cycles

PURPOSE

To evaluate the association between body mass index (BMI) and pregnancy outcomes in women receiving intrauterine insemination (IUI) treatment.

METHODS

The study included 6407 women undergoing 13,745 IUI cycles stratified by BMI. Cox regression was used to analyze the association between BMI and cumulative live births across multiple IUI cycles. A generalized estimating equation (GEE) was used to analyze the live birth rate per cycle.

RESULTS

Compared with normal-weight women (n = 4563), underweight women (n = 990) had a lower cumulative pregnancy and live birth rate (20.71% vs 25.93% and17.17% vs 21.61%, respectively), while overweight women (n = 854) had a higher cumulative pregnancy and live birth rate (31.97%, 26.58%). Adjusted for confounders, the hazard ratio (HR) for achieving live birth following up to a maximum of four IUI cycles was 0.80 (95% CI: 0.67-0.95), comparing underweight with normal weight. In the GEE analyses, low BMI was also associated with a lower per-cycle birth rate (OR 0.79, 95% CI: 0.66-0.95), with adjustment for cycle-specific parameters, including ovarian stimulation, endometrial thickness, and follicular diameter.

CONCLUSION

Low BMI is associated with poor IUI outcomes.

Effect of ovulation before or after intrauterine insemination on pregnancy outcome in patients with unexplained infertility or polycystic ovarian syndrome

OBJECTIVE

To investigate the relationship between ovulation and pregnancy outcomes in patients undergoing intrauterine insemination (IUI).

METHODS

The clinical data from 784 patients, diagnosed with polycystic ovarian syndrome (PCOS) or unexplained infertility, underwent 1624 IUI cycles were analyzed retrospectively. Ovulation was observed by transvaginal ultrasonography on the day of IUI. The clinical pregnancy rate (CPR), abortion rate (AR), and live birth rate (LBR) were analyzed.

RESULTS

The study included 1031 pre-ovulation IUI cycles (63.49%) and 593 post-ovulation IUI cycles (36.51%). The CPR was 13.05%, the AR was 15.57%, and the LBR was 11.02%. Ovulation before or after IUI affected the CPR (11.06% VS 16.53%, p = .002) and LBR (9.41% VS 13.83%, p = .006) per cycle, but did not affect the AR (14.91% VS 16.33%, p = .149). The sex ratio of children was not related to ovulation (p = .948). After adjusting for baseline characteristics and logistic regression, the CPR (OR = 1.931, 95% CI 1.062-1.931, p = .019) and LBR (OR = 1.389, 95% CI 1.007-1.916, p = .045) of post-ovulation insemination were higher than those of pre-ovulation insemination significantly.

CONCLUSION

Pregnancy outcomes were affected by ovulation on the day of IUI in patients with unexplained infertility or PCOS. Post-ovulation insemination may improve the CPR of IUI.

Acupuncture for Female Infertility: Discussion on Action Mechanism and Application

A higher incidence of female infertility has been reported with an unexpectedly early appearance in recent years. The female infertility treatment and application of assisted reproductive technology have recently gained immense interest from scientists. Many studies have discussed the beneficial effects of acupuncture on female infertility. With advancements in science and medical technology, acupuncture-related research has increased in investigating its effectiveness in treating female infertility. This review focuses on a compilation of research in recent years on acupuncture for female infertility treatment and the exploration of the underlying mechanism. For this purpose, literature was searched using various search engines like PubMed, Web of Science, and Google Scholar. The search was refined by only focusing on recent studies on acupuncture effectiveness and mechanism in female infertility and evaluating pregnancy outcomes.

Impact of prolonged one or more natural menstrual cycles on the outcomes of ovulation induction intrauterine artificial insemination pregnancy: a single-centre, retrospective study in China

OBJECTIVES

We determined if the time interval between two ovulation induction intrauterine artificial insemination (IUI) treatment cycles should be extended by one or more natural menstrual cycles in patients undergoing successive cycles of ovulation stimulation, and whether this affects clinical pregnancy rate (CPR).

DESIGN

This study was conducted on infertility patients treated under the ovulation induction programme IUI in a large reproductive centre in China. Study participants were assigned into continuous and discontinuous groups. Differences in baseline clinical pregnancy and abortion rates were compared between the groups. A multivariate logistic model was used to evaluate the effects of time interval on clinical pregnancy outcomes.

SETTING

Reproductive Centre of Maternal and Child Health Hospital of Lianyungang city.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was CPR, the secondary outcome measure was the abortion rate.

RESULTS

A total of 550 IUI treatment cycles involving 275 couples were included in this study. Differences in CPR and abortion rate between the groups were not significant (20.5% vs 21.9% and 27.8% vs 22.0%, p≥0.05). Stratified analyses based on infertility factors did not reveal any significant differences in pregnancy and abortion rates between the groups (p≥0.05). Multivariate analysis showed that increased endometrial thickness correlates with CPR (OR 1.205, 95% CI 1.05 to 1.384, p=0.008). Compared with primary infertility, secondary infertility significantly correlated with improved CPR (OR 2.637, 95% CI 1.313 to 5.298, p=0.006). The effects of time interval between the first two ovulation induction IUI treatment cycles on clinical pregnancy were not significant (OR 1.007, 95% CI 0.513 to 1.974, p=0.985).

CONCLUSIONS

Longer time intervals between the first two ovulation induction IUI treatment cycles did not significantly improve CPR. Therefore, in the absence of clear clinical indications, it may not be necessary to deliberately prolong the interval between two ovulation induction IUI treatment cycles.

Evaluation of the Risk of Birth Defects Related to the Use of Assisted Reproductive Technology: An Updated Systematic Review

Fertility problems constitute a serious medical, social, and demographic problem. With this review, we aim to critically appraise and evaluate the existing literature surrounding the risk of birth defects in offspring conceived using techniques based on assisted reproductive technology (ART). Based on searches of the literature in PubMed and ScienceDirect, we obtained a total of 2,003,275 works related to the topic. Ultimately, 11 original papers published in the last 10 years qualified for inclusion in the study. Based on five studies included in this analysis, it was shown that ART significantly increases the risk of congenital malformations in associated newborns. Due to the specifics of given studies, as well as potential confounding risk factors, this influence cannot be ignored. Therefore, considering the information contained in the articles included in this systematic review, it was determined that the risk of birth defects is not directly related to the use of ART itself but also depends on the age of partners, causes of infertility, comorbidities, and the number of fetuses during a pregnancy, as well as many other factors not covered in the literature. It is thus necessary to impress upon infertile couples who wish to have offspring that the use of ART is not risk-free but that the benefits outweigh the risks. Further education in this field, as well as social understanding, is also required.

Aspiration of excess follicles before intrauterine insemination in high response cycles

Purpose

To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm.

Methods

A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured.

Results

EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period.

Conclusions

EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.

The Effect of Spontaneous LH Surges on Pregnancy Outcomes in Patients Undergoing Letrozole-HMG IUI: A Retrospective Analysis of 6,285 Cycles

BACKGROUND

To date, no consensus has been reached on whether to wait for spontaneous luteinizing hormone (LH) surge to occur or to trigger ovulation regardless of the presence of an LH surge for achieving higher success rate in intrauterine insemination (IUI) cycles. Therefore, we hope to investigate the effect of the presence of a spontaneous LH surge on pregnancy outcomes in letrozole-human menopausal gonadotropin (LE-HMG) IUI cycles.

METHODS

In this retrospective cohort study, a total of 6,285 LE-HMG IUI cycles were included between January 2010 and May 2021. Cycles were categorized into three groups: the trigger + LH surge group, the trigger only group, and the LH surge only group. The primary outcome measure was the clinical pregnancy rate. A logistic regression analysis was performed to explore other risk factors affecting the clinical pregnancy rate.

RESULTS

No significant differences were observed in biochemical pregnancy rate (P =0.640), clinical pregnancy rate (P =0.702), ongoing pregnancy rate (P =0.842), and live birth rate (P =0.951) among the three groups. The binary logistic regression analysis also confirmed that the existence of an LH surge was not associated with clinical pregnancy. There was a difference in ectopic pregnancy rates (P =0.045), but logistic regression showed that the presence of a spontaneous LH surge has no association with ectopic pregnancy. Nonetheless, patients with lead follicles within 18.1-20.0 mm/20.1-22.0 mm and a long duration of LE treatment were less likely to get ectopic pregnant compared with patients with 14.1-16.0 mm lead follicles and shorter LE treatment (OR: 0.142, 95% CI: 0.023-0.891, P =0.037; OR: 0.142, 95% CI: 0.022-0.903, P =0.039; OR: 0.445, 95% CI: 0.235-0.840, P = 0.013).

CONCLUSIONS

The presence of a spontaneous LH surge in triggered LE-HMG IUI cycles does not appear to improve pregnancy rates. Thus, we suggest that waiting for an LH surge to occur is not necessary in triggered LE-HMG IUI cycles.

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

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.

Double versus single intrauterine insemination (IUI) in stimulated cycles for subfertile couples

BACKGROUND

In subfertile couples, couples who have tried to conceive for at least one year, intrauterine insemination (IUI) with ovarian hyperstimulation (OH) is one of the treatment modalities that can be offered. When IUI is performed a second IUI in the same cycle might add to the chances of conceiving. In a previous update of this review in 2010 it was shown that double IUI increases pregnancy rates when compared to single IUI. Since 2010, different clinical trials have been published with differing conclusions about whether double IUI increases pregnancy rates compared to single IUI.

OBJECTIVES

To determine the effectiveness and safety of double intrauterine insemination (IUI) compared to single IUI in stimulated cycles for subfertile couples.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase and CINAHL in July 2020 and LILACS, Google scholar and Epistemonikos in February 2021, together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled, parallel trials of double versus single IUIs in stimulated cycles in subfertile couples.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We identified in nine studies involving subfertile women. The evidence was of low quality; the main limitations were unclear risk of bias, inconsistent results for some outcomes and imprecision, due to small trials with imprecise results. We are uncertain whether double IUI improves live birth rate compared to single IUI (odds ratio (OR) 1.15, 95% confidence interval (CI) 0.71 to 1.88; I² = 29%; studies = 3, participants = 468; low quality evidence). The evidence suggests that if the chance of live birth following single IUI is 16%, the chance of live birth following double IUI would be between 12% and 27%. Performing a sensitivity analysis restricted to only randomised controlled trials (RCTs) with low risk of selection bias showed similar results. We are uncertain whether double IUI reduces miscarriage rate compared to single IUI (OR 1.78, 95% CI 0.98 to 3.24; I² = 0%; studies = 6, participants = 2363; low quality evidence). The evidence suggests that chance of miscarriage following single IUI is 1.5% and the chance following double IUI would be between 1.5% and 5%. The reported clinical pregnancy rate per woman randomised may increase with double IUI group (OR 1.51, 95% CI 1.23 to 1.86; I² = 34%; studies = 9, participants = 2716; low quality evidence). This result should be interpreted with caution due to the low quality of the evidence and the moderate inconsistency. The evidence suggests that the chance of a pregnancy following single IUI is 14% and the chance following double IUI would be between 16% and 23%. We are uncertain whether double IUI affects multiple pregnancy rate compared to single IUI (OR 2.04, 95% CI 0.91 to 4.56; I² = 8%; studies = 5; participants = 2203; low quality evidence). The evidence suggests that chance of multiple pregnancy following single IUI is 0.7% and the chance following double IUI would be between 0.85% and 3.7%. We are uncertain whether double IUI has an effect on ectopic pregnancy rate compared to single IUI (OR 1.22, 95% CI 0.35 to 4.28; I² = 0%; studies = 4, participants = 1048; low quality evidence). The evidence suggests that the chance of an ectopic pregnancy following single IUI is 0.8% and the chance following double IUI would be between 0.3% and 3.2%.

AUTHORS' CONCLUSIONS

Our main analysis, of which the evidence is low quality, shows that we are uncertain if double IUI improves live birth and reduces miscarriage compared to single IUI. Our sensitivity analysis restricted to studies of low risk of selection bias for both outcomes is consistent with the main analysis. Clinical pregnancy rate may increase in the double IUI group, but this should be interpreted with caution due to the low quality evidence. We are uncertain whether double IUI has an effect on multiple pregnancy rate and ectopic pregnancy rate compared to single IUI.

Is controlled ovarian stimulation and insemination an effective treatment in older women with male partners with decreased total motile sperm counts?

OBJECTIVE

To assess the effect of the total motile sperm counts (TMSC) on the success of controlled ovarian stimulation (COH) and intra-uterine insemination (IUI) in women 38-42 years of age.

STUDY DESIGN

A database of all women aged 38-42 years who underwent IUI with stimulation at a University Reproductive Centre between 2009 and 2018 inclusive was developed. Including stimulation with clomiphene citrate, letrozole or gonadotropins and divided into TMSC 5.00-10.0 mil and < 5.00 mil. Statistics were compared with multivariate logistic regression, t tests or Chi-squared tests.

RESULTS

A total of 397 cycles of IUI in 397 patients were included, of which, 190 cycles with TMSC 5.00-10.0 and 207 cycles with TMSC < 5.00. There were no statistical differences in the baseline characteristics between the two groups including: age (P = 0.2), gravidity (P = 0.7), parity (P = 0.6), basal FSH (P = 0.2), basal E2 (P = 0.4), antral follicular count (P = 0.5) and the number of mature follicles stimulated (P = 0.2). As expected, TMSC was 7.6 ± 1.5 mil in the first group and 2.4 ± 1.6 mil in the second group (P < 0.0001). The clinical pregnancy rate per cycle in the 5.01-10.00 TMSC group was 9.5 vs. 3.4% when TMSC < 5.00 (P = 0.01). When evaluating only women 40-42 years of age (99 women in the 5.00-10.00 TMSC group and 95 in the group of TMSC < 5.00); the pregnancy rates were not statistically different between the two groups (7 vs. 7.3%, P = 1), nor was the clinical pregnancy rate (5 vs. 6.3%, P = 0.7).

CONCLUSIONS

Women 38-39 years of age have poorer outcomes at COH/IUI when TMSC < 5 million than if it is 5-10 million. Once a woman is 40 years of age, this effect is lost. With TMSC 5-10 million, women 38-39 years of age have respectable outcomes at COH/IUI. Clinical pregnancy rates are very low in women 40 years of age with TMSC ≤ 10 million or 38-39 years old with TMSC < 5 million and other treatments should be offered.

Intrauterine insemination with ovarian stimulation is a successful step prior to assisted reproductive technology for couples with unexplained infertility

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.

Social sperm freezing

Increased paternal age has been associated with lower fertility and higher genetic risk for the offspring. One way to prevent these consequences is to freeze sperm at a young age. Social sperm freezing could be developed in a way similar to social oocyte freezing. The main difference between freezing oocytes and sperm is that social sperm freezing is much less focussed on fertility preservation and much more on avoiding increased genetic risk. Contrary to what some people seem to believe, sperm freezing is more complicated than it looks at first sight. This article considers three practical aspects: freezing, storage and testing. It is concluded that the remedy (cryopreservation) may itself cause damage to the quality of the spermatozoon and to its genetic integrity, thus undoing the possible benefits in terms of fertility and health of offspring.

Cost-effectiveness of ovarian stimulation agents for IUI in couples with unexplained subfertility

STUDY QUESTION

Which agent for ovarian stimulation (OS) is the most cost-effective option in terms of net benefit for couples with unexplained subfertility undergoing IUI?

SUMMARY ANSWER

In settings where a live birth is valued at €3000 or less, between €3000 and €55 000 and above €55 000, clomiphene citrate (CC), Letrozole and gonadotrophins were the most cost-effective option in terms of net benefit, respectively.

WHAT IS KNOWN ALREADY

IUI-OS is a common first-line treatment for couples with unexplained subfertility and its increased uptake over the past decades and related personal or reimbursed costs are pressing concerns to patients and health service providers. However, there is no consensus on a protocol for conducting IUI-OS, with differences between countries, clinics and settings in the number of cycles, success rates, the agent for OS and the maximum number of dominant follicles in order to minimise the risk of a multiple pregnancy. In view of this uncertainty and the association with costs, guidance is needed on the cost-effectiveness of OS agents for IUI-OS.

STUDY DESIGN, SIZE, DURATION

We developed a decision-analytic model based on a decision tree that follows couples with unexplained subfertility from the start of IUI-OS to a protocoled maximum of six cycles, assuming couples receive four cycles on average within one year. We chose the societal perspective, which coincides with other perspectives such as that from health care providers, as the treatments are identical except for the stimulation agent. We based our model on parameters from a network meta-analysis of randomised controlled trials for IUI-OS. We compared the following three agents: CC (oral medication), Letrozole (oral medication) and gonadotrophins (subcutaneous injection).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The main health outcomes were cumulative live birth and multiple pregnancy. As the procedures are identical except for the agent used, we only considered direct medical costs of the agent during four cycles. The main cost-effectiveness measures were the differences in costs divided by the differences in cumulative live birth (incremental cost-effectiveness ratio, ICER) and the probability of the highest net monetary benefit in which costs for an agent were deducted from the live births gained. The live birth rate for IUI using CC was taken from trials adhering to strict cancellation criteria included in a network meta-analysis and extrapolated to four cycles. We took the relative risks for the live birth rate after Letrozole and gonadotrophins versus CC from that same network meta-analysis to estimate the remaining absolute live birth rates. The uncertainty around live birth rates, relative effectiveness and costs was assessed by probabilistic sensitivity analysis in which we drew values from distributions and repeated this procedure 20 000 times. In addition, we changed model assumptions to assess their influence on our results.

MAIN RESULTS AND THE ROLE OF CHANCE

The agent with the lowest cumulative live birth rate over 4 IUI-OS cycles conducted within one year was CC (29.4%), followed by Letrozole (32.0%) and gonadotrophins (34.5%). The average costs per four cycles were €362, €434 and €1809, respectively. The ICER of Letrozole versus CC was €2809 per additional live birth, whereas the ICER of gonadotrophins versus Letrozole was €53 831 per additional live birth. When we assume a live birth is valued at €3000 or less, CC had the highest probability of maximally 65% to achieve the highest net benefit. Between €3000 and €55 000, Letrozole had the highest probability of maximally 62% to achieve the highest net benefit. Assuming a monetary value of €55 000 or more, gonadotrophins had the highest probability of maximally 56% to achieve the highest net benefit.

LIMITATIONS, REASONS FOR CAUTION

Our model focused on population level and was thus based on average costs for the average number of four cycles conducted. We also based the model on a number of key assumptions. We changed model assumptions to assess the influence of these assumptions on our results.

WIDER IMPLICATIONS OF THE FINDINGS

The high uncertainty surrounding our results indicate that more research is necessary on the relative effectiveness of using CC, Letrozole or gonadotrophins for IUI-OS in terms of the cumulative live birth rate. We suggest that in the meantime, CC or Letrozole are the preferred choice of agent.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by ZonMw Doelmatigheidsonderzoek, grant 80-85200-98-91072. The funder had no role in the design, conduct or reporting of this work. BWM is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research support from ObsEva, Merck and Guerbet. All other authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Outcomes of donor versus partner sperm in intrauterine insemination in women aged 38 years and older

OBJECTIVE

To compare pregnancy rates of donor versus partner sperm in intrauterine insemination (IUI) cycles in women aged 38 years and above.

METHODS

A retrospective cohort study was performed using data from 944 women aged 38-43 years old who underwent a combined 1596 IUI cycles at an academic fertility clinic in Montreal, Canada between February 2009 to April 2018.

RESULTS

Partner sperm was used in 1421 cycles (89.0%), and donor sperm was inseminated in 175 cycles (11.0%). Mean ages of the women were 39.8 (±1.5) and 40.2 (±1.6) years in the partner and donor insemination groups, respectively (P < 0.001). Positive serum (β human chorionic gonadotropin) pregnancy rate in the partner sperm group was 9.0% (n = 128) whereas that in the donor insemination group was 9.7% (n = 17) (P = 0.759). Clinical pregnancy rates were 5.8% (n = 83) and 8.0% (n = 14) in the respective groups (P = 0.260). There were five multiple gestation (twin) pregnancies in the cohort, three in those undergoing IUI with partner sperm and two in those undergoing IUI with donor sperm.

CONCLUSION

In women aged 38-43 years undergoing IUI with controlled ovarian stimulation, using donor sperm, compared with partner sperm, did not increase rate of pregnancy.

The interval between insemination and ovulation predicts outcome after intrauterine insemination with donor sperm (IUI-D)

OBJECTIVE

To identify whether the time interval from insemination to ovulation (I-O interval) affects outcome after intrauterine insemination with donor sperm (IUI-D).

METHODS

A retrospective study was conducted in a public assisted reproductive medicine center between January, 2014 and December, 2016 in Xi'an, China. The data were collected from the medical records and generalized estimating equations (GEEs) were used to evaluate the effects of various variables on IUI outcome.

RESULTS

A total of 2091 IUI-D cycles from 1165 couples were included in this study. Multiple predictors were identified for (live birth rate) LBR. The I-O interval was the predictor for LBR. An I-O interval ≥19 h significantly decreased CPR (odds ratio [OR], 95% confidence interval [CI]: 0.29, 0.17-0.48) and LBR (OR, 95% CI: 0.32, 0.19-0.55). The presence of at least two follicles ≥18 mm on ovulation day significantly increased the LBR (OR, 95%CI: 1.27, 1.01-1.60). Women aged 35 years and older had a significantly decreased LBR (OR, 95% CI: 0.61, 0.38-0.98).

CONCLUSION

The I-O interval, a new prognostic factor, in combination with the woman's age and number of mature follicles, can predict the outcome after IUI-D. IUI-D is best performed within 19 h of I-O interval for a higher probability of clinical pregnancy and live birth.

Time intervals between semen production, initiation of analysis, and IUI significantly influence clinical pregnancies and live births

PURPOSE

Does IDEF mapping help monitor the technical process of IUI and explore the potential improvements which might contribute to increased pregnancy and live birth rates?

METHOD

Retrospective analysis of 1729 homologous IUI cycles of couples attending a fertility clinic in a university hospital setting. Standardized conventional semen parameters were analyzed and the semen samples prepared via discontinuous density gradient centrifugation.

RESULTS

There was no significant association between sperm concentration, motility and morphology (analysis phase), and pregnancy outcome. Only female and male ages were significantly associated with the pregnancy outcome. There was a significant difference in the odds on clinical pregnancies and live births when analysis was ≤ 21 min initiated, and < 107 min between sample production and IUI, adjusted for male and female age.

CONCLUSIONS

Adjusting for the couple's age, we could show that time intervals between semen production and analysis and IUI when kept low significantly influenced clinical pregnancies and live births.

Ovulation before or after intrauterine insemination does not affect live birth rates: a retrospective cohort study of 6701 cycles

RESEARCH QUESTION

Should intrauterine insemination be carried out before or after follicle rupture, and is there a difference in sex ratio, according to follicle rupture at the time of insemination?

DESIGN

In this retrospective cohort study conducted at the Fertility Clinic, Odense University Hospital, Denmark, data from 6701 homologous insemination cycles were analysed. Follicle rupture was determined by transvaginal ultrasonography at the time of insemination. The pregnancy rate, clinical pregnancy rate (CPR) and live birth rate (LBR) were recorded.

RESULTS

In 2831 cycles (42.2%), follicle rupture had occurred at the time of insemination, whereas, in 3870 cycles (57.8%), no follicle rupture had occurred at the time of insemination. Overall, 1186 (17.7%) cycles resulted in a positive pregnancy test and no significant differences were found in pregnancy rate between rupture and no rupture of follicle (17.8% versus 17.7%, P = 0.90). Follicle rupture before or after insemination did not affect CPR (14.8% versus 15.0%, P = 0.86) or LBR (11.9% versus 12.2%, P = 0.75) per cycle. Moreover, the sex ratio of children born did not depend on follicle rupture (P = 0.20). After logistic regression with cluster and adjusting for baseline characteristics, no significant differences between groups were observed.

CONCLUSION

Ovulation at the time of insemination is not associated with pregnancy rate, CPR, LBR or gender.

Pregnancy predictors in unexplained infertility after intrauterine insemination

BACKGROUND

Intrauterine insemination (IUI) is a first-line treatment for unexplained infertility (UI). There was a compelling need for the improvement of pregnancy rate in females with UI.

OBJECTIVE

To explore the pregnancy predictors in cases of UI undergoing IUI.

METHOD

A total of 212 couples who underwent 446 IUI cycles were involved the study. Different factors were grouped to explore the influencing factors of IUI for UI.

RESULT

Female age and somking affected pregnancy outcomes. As the number of treatment cycles increased, the pregnancy rate increased. The BMI, treatment regimens, type of infertility, endometrium, and timing insemination have no significant prognostic value.

CONCLUSION

Apart from the number of treatment cycles, somking, and female age, no other factors had prognostic value. More studies and samples are necessary to evaluate whether other factors affect conception.