The potential use of intrauterine insemination as a basic option for infertility: a review for technology-limited medical settings

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.

The Effect of Endometrial Scratch on Pregnancy Rate in Women with Previous Intrauterine Insemination Failure: a Systematic Review and Meta-analysis of Randomized Controlled Trials

The objective of this study was to evaluate the impact of endometrial scratch on the pregnancy rate among women with previous failed intrauterine insemination (IUI). A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI web of science from inception to November 2021. We selected randomized clinical trials (RCTs) that compared endometrial scratch in the intervention group versus placebo or no intervention in the control group among infertile women with previous failure of IUI regarding different pregnancy outcomes. Revman software was utilized for performing our meta-analysis. Our main outcomes were biochemical pregnancy, clinical pregnancy, and live birth rates. Five RCTs met our inclusion criteria with a total number of 989 patients. We found endometrial scratch significantly improved the biochemical and clinical pregnancy rates in comparison with the control group among women with previous IUI failure (p < 0.001). Moreover, the live birth rate was significantly increased among the endometrial scratch group (RR = 2.00, 95% CI [1.20, 3.34], p = 0.008). In conclusion, endometrial scratch is effective in improving pregnancy outcomes among women with previous IUI failure. More trials are required to confirm our findings.

The Effect of the Time Interval From Sperm Processing to Intrauterine Insemination on the Pregnancy Outcomes of Infertile Women

Objective: Intrauterine insemination (IUI) is the first-line treatment in couples suffering from various causes of subfertility and infertility. Considering the relatively low rate of pregnancy achieved with each cycle in this method, optimizing various steps in the process including the time interval from sperm collection to IUI may result in an increased rate of success. The goal of this study was to assess the impact of time intervals from the end of sperm processing to IUI (SP-IUI) on the pregnancy rate in IUI. Materials and methods: This single-center prospective cohort study evaluated couples with normal male partner sperm analysis and idiopathic female infertility undergoing IUI from 2018 to 2021. Cycles were stimulated using subcutaneous recombinant FSH and oral Letrozole. Ovulation was triggered using GnRH antagonist when the leading follicle's size reached greater than 14mm. The participants were placed in one of the three groups based on SP-IUI: group 1 (0-60 min), group II (60-90 min), and Group III: (>90 min). Results: 269 couples were included in the study. Sperm processing expectedly resulted in an increased concentration of total sperm count and sperm motility (P<0.001). The rate of chemical or clinical pregnancy, abortion, IUFD, multigestation, pregnancy, term birth, and ectopic pregnancy was not significantly different across study groups (P>0.05). Conclusion: The results of this study suggest that SP-IUI intervals evaluated in this study do not vary in terms of pregnancy rate or adverse pregnancy outcomes in IUI with normal male partner semen analysis. Hence, infertile couples can be flexible in the collection of semen specimens without time and site (at home or hospital) limitations.

Effect of Blood Homocysteine on the Outcome of Artificial Insemination in Women with Polycystic Ovary Syndrome

Background

Polycystic ovary syndrome (PCOS) is the major reason for women's low fertility and the most frequent endocrine disorder in women of childbearing age. Homocysteine is an amino acid that contains sulfur that has been negatively correlated with the reproductive outcome of polycystic women treated with IVF/ICSI. However, the impact of blood homocysteine levels on the outcome of artificial insemination in polycystic ovary syndrome women is unknown. The goal of this study is to examine the impact of serum homocysteine on the result of intrauterine insemination in females who have polycystic ovary syndrome (PCOS).

Methods

96 infertile women (129 cycles) treated with artificial insemination were collected, including 66 cases (87 cycles) in the case group (PCOS group) and 30 cases (42 cycles) in the control group (male factor infertility). The differences in general data amongst two groups, such as BMI, Hcy, and age, were compared. The case group has been classified into two groups based on serum Hcy level: LHcy group (Hcy < 15) and HHcy group (Hcy ≥ 15). The relationship among pregnancy and serum Hcy level outcome in PCOS women was compared.

Results

The PCOS group had substantially increased serum homocysteine levels in comparison to the control group (P = 0.019). Among PCOS women, the clinical pregnancy rates of artificial insemination in the HHcy group and LHcy group were 14.29% and 37.88%. The difference among the two groups was substantial (P = 0.044). Artificial insemination frequency, ovulation induction, BMI, infertility years, AMH, serum testosterone, HOME IR, TSH, TPOAb, hCG, daily follicle size, intimal thickness, and other factors did not differ greatly between the two groups.

Conclusion

Serum homocysteine levels are increased in women having PCOS. Their levels above the threshold will lower the clinical pregnancy rate of intrauterine insemination in PCOS women.

Causes and Risk Factors for Male Infertility: A Scoping Review of Published Studies

Background

Despite the evidence of declining sperm counts worldwide and the increasing prevalence of male infertility, there has been limited documentation of the potential causes and risk factors for male infertility. With limited methods of primary treatment of male infertility, understanding the causes and risk factors will pinpoint specific lines of prevention.

Objective

We reviewed published studies on causes and risk factors for male infertility and identify gaps in the literature enabling more focused research and innovations.

Design/Setting

The study was a scoping review. The review included studies on the causes and risk factors of male infertility published in scientific/academic publications. It was not limited to any region or date. The following databases were searched: Cumulative Index to Nursing and Allied Health Literature, Wiley online, HINARI, Science Direct, PubMed/Medline, Google Scholar, African Journals Online, and the WHO Repository. In total, 1295 articles were identified. After removing 357 duplicates, 938 articles were screened, and 71 articles were identified for inclusion, while 60 articles met the inclusion criteria.

Results

Four broad causes and risk factors of male infertility identified were 1) biological/physiological/genetic causes, 2) behavioral/lifestyle risk factors, 3) environmental factors, and 4) socio-demographic risk factors. However, no substantive results on actual causes under each category were identified, leaving gaps for further research and experimentation.

Conclusion

The results indicate limited knowledge of the actual causes of male infertility in published studies. The gaps in knowledge that need to be bridged to enable a fuller understanding of the actual causes of male infertility were highlighted.

Factors Affecting Artificial Insemination Pregnancy Outcome

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.

The effect of a natural vaginal product based on honey on the success of intrauterine insemination (IUI) in infertility treatment

OBJECTIVE

Due to high prevalence of infertility and increasing tendency towards complementary medicine, this study was conducted to investigate the effect of a vaginal natural product based on honey and 1% extract of Myristica fragrans on the extent of success of intrauterine insemination (IUI).

MATERIALS AND METHODS

This non-randomized clinical trial study with a historic control group, was performed on infertile women. In this trial, 159 patients were assigned to the intervention group, and 288 patients were recruited to the control group. All the participants received clomiphene or letrozole from the third up to seventh day of menstruation, and on days 6, 7, and 8, they received human menopausal gonadotrophin (HMG) injections. IUI was performed 36 hours after human chorionic gonadotrophin (HCG) injection. In the intervention group, a natural vaginal product was used besides the above treatments, from menstruation day 7 until the day before performing IUI. Sixteen days after IUI, serum beta HCG was measured to investigate chemical pregnancy, and six weeks following IUI, vaginal sonography was performed to investigate clinical pregnancy.

RESULTS

Analysis showed that the pregnancy rate was higher in the group that receiving the natural product compared to the control group. Chemical pregnancy rate was 18.1% vs. 15.4%, and clinical pregnancy rate was 15.2% vs. 13.8% for intervention and control groups, respectively; but, this difference was not significant.

CONCLUSION

It seems that the use of this vaginal product for a longer period of time and across several menses cycles before IUI, may produce more positive results. Further studies, however, are needed to be done.

Bilateral tubo-ovarian abscesses presenting with huge pelvic mass after repeated intrauterine inseminations in a woman with severe endometriosis

A 32-year-old woman consulted for an evaluation of pelvic pain following intrauterine insemination (IUI). Vaginal and abdominal sonography, septic workup were performed and laparoscopic surgery was scheduled after failure to respond to a course of antibiotics. During laparoscopic surgery, bilateral tubo-ovarian abscesses arising on the endometriotic cysts of both ovaries were identified with a vast amount of brownish peritoneal fluid under the adhesion of the greater omentum. Bilateral ovarian cystectomy, right salpingectomy and lysis adhesion were performed. Pathologic organisms were not detected in any of the specimen cultures. Pelvic infection is an uncommon complication following IUI. Endometriosis might be a risk factor predisposing the pelvic organ to be susceptible to such infection. Performing IUI in a patient with endometriosis should be done with great vigilance.

Effect of Gonadotropin Types and Indications on Homologous Intrauterine Insemination Success: A Study from 1251 Cycles and a Review of the Literature

Objective

To evaluate the IUI success factors relative to controlled ovarian stimulation (COS) and infertility type, this retrospective cohort study included 1251 couples undergoing homologous IUI.

Results

We achieved 13% clinical pregnancies and 11% live births. COS and infertility type do not have significant effect on IUI clinical outcomes with unstable intervention of various couples' parameters, including the female age, the IUI attempt rank, and the sperm quality.

Conclusion

Further, the COS used seemed a weak predictor for IUI success; therefore, the indications need more discussion, especially in unexplained infertility cases involving various factors. Indeed, the fourth IUI attempt, the female age over 40 years, and the total motile sperm count <5 × 10⁶ were critical in decreasing the positive clinical outcomes of IUI. Those parameter cut-offs necessitate a larger analysis to give infertile couples more chances through IUI before carrying out other ART techniques.

The effect of problem-solving skill training on mental health and the success of treatment of infertile women under intrauterine insemination treatment

INTRODUCTION

Using fertility treatment will cause high levels of anxiety and depression. The study was carried out with the objective of determining the effect of problem-solving skills (PSS) training on mental health and the success of treatment of infertile women under intrauterine insemination (IUI) treatment.

MATERIALS AND METHODS

this randomized clinical trial was carried out on 72 women referring to Milad Infertility Center in Mashhad. Individuals were randomly assigned into control and intervention groups. PSS were taught in three sessions in the intervention group, and the control group received usual care. The success rate of therapy and the mean of anxiety and depression on the day of IUI operation were compared using the Beck Depression Inventory and Spielberger Anxiety Inventory in both groups. t-test, Mann-Whitney, paired t-test, Wilcoxon, and Chi-square tests were used to analyze the data.

RESULTS

on the day of IUI operation, the mean score of state anxiety in the control group(5 0. 11 ± 8.51) and PSS (68.12 ± 11.49) was significant (P < 0.001), trait anxiety in the control group (46.41 ± 8.70) and PSS (44.00 ± 9.92) was significant (P < 0.001), and depression in the control group (17.44 ± 11.70) and PSS (12.99 ± 8.99) was significant (P < 0.001); however, the success of treatment in both groups (14.7% and PSS (26.5%) was not significantly different (P = 0.230).

CONCLUSION

Considering the effect of problem-solving on reducing anxiety and depression, it is suggested that infertility center of this intervention should be used.

Intrauterine Insemination: Fundamentals Revisited

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. It is a cost-effective, noninvasive first-line therapy for selected patients with functionally normal tubes, and infertility due to a cervical factor, anovulation, moderate male factor, unexplained factors, immunological factor, and ejaculatory disorders with clinical pregnancy rates per cycle ranging from 10 to 20%. It, however, has limited use in patients with endometriosis, severe male factor infertility, tubal factor infertility, and advanced maternal age ≥ 35 years. IUI may be performed with or without ovarian stimulation. Controlled ovarian stimulation, particularly with low-dose gonadotropins, with IUI offers significant benefit in terms of pregnancy outcomes compared with natural cycle or timed intercourse, while reducing associated COH complications such as multiple pregnancies and ovarian hyperstimulation syndrome. Important prognostic indicators of success with IUI include age of patient, duration of infertility, stimulation protocol, infertility etiology, number of cycles, timing of insemination, number of preovulatory follicles on the day of hCG, processed total motile sperm > 10 million, and insemination count > 1 × 106 with > 4% normal spermatozoa. Alternative insemination techniques, such as Fallopian tube sperm perfusion, intracervical insemination, and intratubal insemination, provide no additional benefit compared to IUI. A complete couple workup that includes patient history, physical examination, and clinical and laboratory investigations is mandatory to justify the choice in favor of IUI and guide alternative patient management, while individualizing the treatment protocol according to the patient characteristics with a strict cancelation policy to limit multi-follicular development may help optimize IUI pregnancy outcomes.

Ovarian stimulated cycle: not a better alternative for women without ovulation disorder in intrauterine insemination

To explore the related factors on the clinical pregnancy outcome in intrauterine insemination, a retrospective study was conducted on the clinical data of 580 cycles for 301 infertile couples who were treated with intrauterine insemination. The female age, male age, duration of infertility, treatment protocols, endometrial thickness and sperm parameters were compared between pregnant group and non-pregnant group. The results showed that there were statistical differences in female age, duration of infertility and endometrial thickness between the two groups. The pregnancy rate was 19.34% in Group A (female age ≤ 30 y) compared with 10.91% in Group B (female age > 30 y). The pregnancy rate was 18.44% when the duration of infertility ≤ 2 years, which was higher than another group 10.73% when the duration of infertility > 2 years. Group analysis according to endometrial thickness (Group1: < 8 mm; Group 2: ≥ 8 mm and ≤ 12 mm; Group 3: > 12 mm) demonstrated significant differences in clinical pregnancy rate (7.41%, 18.00% and 11.48% respectively). For those infertile female without ovulation failure, the higher clinical pregnancy rates were observed in patients undergoing intrauterine insemination in natural cycle 16.12% when compared with the patients in ovarian stimulated cycles 10.48%. Thus, we demonstrate that the pregnancy rate is related with female age, duration of infertility and endometrial thickness. The ovarian stimulated cycle couldn’t improve the pregnancy outcome for those women without ovulation disorder in intrauterine insemination.

Thyroxin Is Useful to Improve Sperm Motility

Background

The aim of this study was to evaluate the non-genomic action of thyroxin on sperm kinetic and its probable use to improve sperm recovery after applying an en- richment method like “swim-up” in comparison with the available one, pentoxifylline.

Materials and Methods

This is an experimental study. A total of 50 patients were re- cruited, followed by infertility consultation. Conventional sperm assays were performed according to World Health Organization criteria-2010 (WHO-2010). A Computer Aided Semen Analysis System was employed to assess kinetic parameters and concentrations. Number of the motile sperm recovered after preparation technique was calculated.

Results

Addition of T4 (0.002 µg/ml) to semen samples increased hypermotility at 20 minutes (control: 14.18 ± 5.1% vs. 17.66 ± 8.88%, P<0.03, data expressed as mean ± SD) and remained unchanged after 40 minutes. Significant differences were found in the motile sperm recovered after swim-up (control: 8.93×10⁶ ± 9.52× 06vs. 17.20×10⁶ ± 21.16×10⁶, P<0.03), achieving all of the tested samples a desirable threshold value for artificial insemination outcome, while adding pentoxifylline increased the number of recovered sperm after swim-up in 60% of the studied cases. No synergism between two treatments could be determined.

Conclusion

We propose a new physiological tool to artificially improve insemination. The discussion opens windows to investigate unknown pathways involved in sperm ca- pacitation and gives innovative arguments to better understand infertility mechanisms.

Outcomes after intrauterine insemination are independent of provider type

OBJECTIVE

We sought to determine whether the success of intrauterine insemination (IUI) varies based on the type of health care provider performing the procedure.

STUDY DESIGN

This was a retrospective cohort study set at an infertility clinic at an academic institution. The patients who comprised this study were 1575 women who underwent 3475 IUI cycles from late 2003 through early 2012. Cycles were stratified into 3 groups according to the type of provider who performed the procedure: attending physician, fellow physician, or registered nurse (RN). The primary outcome was live birth. Additional outcomes of interest included positive pregnancy test and clinical pregnancy. Repeated measures log binomial regression was used to estimate the risk ratios (RR) and 95% confidence intervals (CI) for the outcomes and to evaluate the effect of potential confounders. All tests were 2-sided, and P values < .05 were considered statistically significant.

RESULTS

Of the 3475 IUI cycles, 2030 (58.4%) were gonadotropin stimulated, 929 (26.7%) were clomiphene citrate stimulated, and 516 (14.9%) were natural. The incidences of clinical pregnancy and live birth among all cycles were 11.8% and 8.8%, respectively. After adjusting for female age, male partner age, and cycle type, the incidence of live birth was similar for RNs compared with attending physicians (RR, 0.80; 95% CI, 0.58-1.1) and fellow physicians compared with attending physicians (RR, 0.84; 95% CI, 0.58-1.2). Similar results were seen for positive pregnancy test and clinical pregnancy.

CONCLUSION

There was no significant difference in live birth following IUI cycles in which the procedure was performed by a fellow physician or RN compared with an attending physician.

Influence of follicle rupture and uterine contractions on intrauterine insemination outcome: a new predictive model

OBJECTIVE

To correlate the detection of follicle rupture and the number of uterine contractions per minute with the outcome of IUI and to build a predictive model for the outcome of IUI including these parameters.

DESIGN

Retrospective cohort study.

SETTING

Fertility clinic.

PATIENT(S)

We analyzed data from 610 women who underwent homologous or donor double IUI from 2005 to 2010 and whose data of uterine contractions or follicle rupture were recorded.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live-birth rate.

RESULT(S)

Nine hundred seventy-nine IUI cycles were included. The detection of follicle rupture (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.30-3.01) and the number of uterine contractions per minute (OR, 1.67; 95% CI, 1.02-2.74) assessed after the second insemination procedure of a double IUI were positively correlated with the live-birth rate. A multiple logistic regression model showed that sperm origin, maternal age, follicle count at hCG administration day, follicle rupture, and the number of uterine contractions observed after the second insemination procedure were significantly associated with the live-birth rate.

CONCLUSION(S)

Follicle rupture and uterine contractions are associated with the success of an IUI cycle. This may open new possibilities to improve the methodology of IUI.

The impact of thyroid function on intrauterine insemination outcome--a retrospective analysis

BACKGROUND

Hashimoto's thyroiditis is the most common endocrinopathy in premenopausal women, and is associated with various gynecological problems, including recurrent miscarriage and unexplained infertility. A possible influence of Hashimoto's thyroiditis on the success of intrauterine insemination seems likely, but has not been evaluated as yet. Therefore, the aim of our study was to retrospectively analyze the impact on intrauterine insemination outcome of thyroid function and markers suggestive for Hashimoto's thyroiditis.

METHODS

Retrospective cohort study in a tertiary care center of 540 women who underwent Intrauterine Insemination. The clinical pregnancy rate was the main outcome parameters. The following possible influencing factors were tested: thyroid-stimulating hormone (TSH); thyroid autoantibodies; age; body mass index; type of sterility (primary/secondary); parity; male factor; presence of PCO syndrome; ovulation induction; ovarian stimulation; and current thyroid medication.

RESULTS

The overall clinical pregnancy rate was 6.9% (37/540). Age, thyroid hormone supplementation for thyroid-stimulating hormone (TSH) levels>2.5 micro-IU/ml, and ovulation induction with HCG were significantly predictive in the multivariate analysis (p<0.05) as influencing factors for the pregnancy rate after intrauterine insemination.

CONCLUSIONS

Women undergoing intrauterine insemination seem to benefit from a strict thyroid hormone supplementation regimen in order to achieve lower TSH levels.

Prognosis factors of pregnancy after intrauterine insemination with the husband's sperm: conclusions of an analysis of 2,019 cycles

OBJECTIVE

To identify the prognostic factors for pregnancy after intrauterine insemination with the husband's sperm (IUI-H).

DESIGN

Retrospective study.

SETTING

A single university medical center.

PATIENT(S)

851 couples, for 2,019 IUI-H cycles.

INTERVENTION(S)

After controlled ovarian stimulation, IUI-H performed 36 hours after ovulation triggering or 24 hours after a spontaneous luteinizing hormone (LH) surge.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per cycle (PR) and delivery rate per cycle (DR).

RESULT(S)

The overall PR was 14.8% and DR 10.8%. Higher PR and DR were observed for patients presenting with ovulation disorders (particularly polycystic ovary syndrome) or with male infertility. Secondary infertility in the woman appeared to be a positive prognostic factor as did a basal follicle-stimulating hormone (FSH) level ≤ 7 IU/L and ovulation triggering over spontaneous LH rise. The other parameters influencing the results were the women's age, the number of mature follicles obtained (≥ 2), the endometrial thickness (10-11 mm), and the number of progressive motile spermatozoa inseminated (>1 million).

CONCLUSION(S)

In women aged ≤ 38 years, IUI-H should be considered as an option, particularly in cases of female infertility from ovulation disorders, in cases of a normal ovarian reserve, in cases of secondary infertility, or when ≥ 1 million progressive sperm are inseminated. Bifollicular stimulation is required. In other cases, in vitro fertilization should be discussed as the first-line treatment.

Comparing the roles of sperm chromatin integrity and apoptosis in intrauterine insemination outcomes of couples with mild male and female factor infertility

BACKGROUND

Intrauterine insemination (IUI) is one of the therapeutic approaches for infertility. The objective of this study was to evaluate DNA integrity and apoptosis role in success of IUI in both mild male and female factor infertility.

METHODS

PATIENTS WERE DIVIDED INTO TWO GROUPS: M (mild male factor; n = 29) and F (female factor; n = 31) undergoing single IUI. Ejaculates were analyzed and chromatin quality was assessed using chromomycin A3 (CMA3) staining. In addition, spermatozoal apoptosis was recognized using TUNEL assay. Statistical analyses were done using t-test and Mann Whitney test for sperm apoptosis and sperm chromatin by SPSS. Data were expressed in mean±SD for variables. P < 0.05 was considered statistically significant.

RESULTS

Sperm concentration and progressive motility were higher in F than M group. Sperm with normal morphology were statistically similar in M and F infertile patients (32.7±15.6% vs. 35.5±9.07%, p = 0.39). Sperm chromatin immaturity was higher in patients with mild male infertility, when compared with the other group (p < 0.01). Also, 32.0±5.6% and 30.8±6.1% of the spermatozoa showed signs of apoptosis in groups M and F, respectively (p = 0.49). Very low (3.4%) clinical pregnancy rates were noticed in patients with mild male factor infertility.

CONCLUSION

Defect in sperm motility as well as high rates of DNA damage and apoptosis may be involved with very low rate of pregnancy outcomes in patients with mild male factor infertility. Therefore, it seems the application of IUI may have better outcomes in patients with female infertility compared to mild male factor infertility.

Controlled ovarian hyperstimulation in women with polycystic ovarian syndrome with or without intrauterine insemination

OBJECTIVE

To evaluate the value of intrauterine insemination (IUI) in controlled ovarian hyperstimulation (COH) among couples with polycystic ovary syndrome (PCOS) and normal semen analysis.

DESIGN

Retrospective cohort study.

SETTING

University teaching center.

PATIENTS

PCOS couples with normal semen analysis that underwent COH with IUI or timed intercourse (TIC).

INTERVENTION

COH with clomiphene citrate, letrozole or gonadotropins with or without IUI.

MAIN OUTCOME MEASURES

Clinical pregnancy rates.

RESULTS

Of a total 265 cycles, 151 cycles were with IUI and 114 others with TIC. No significant difference was found in the overall pregnancy rates between the TIC group (17.5%) and the IUI group (16.6%). Analysis of pregnancy rates according to the type of COH treatments did not demonstrate the advantages of IUI over TIC.

CONCLUSION

Compared to timed intercourse, IUI does not increase the pregnancy rate in couples with PCOS and normal semen analysis treated with COH.

The effects of timing of intrauterine insemination in relation to ovulation and the number of inseminations on cycle pregnancy rate in common infertility etiologies

BACKGROUND

Controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI) is an established tool in medically assisted conception for many infertility factors. However, the proper timing of IUI after hCG trigger and the frequency of IUI are still debated. We aimed to examine the association between the cycle pregnancy rate (CPR) and: (i) single IUI timed at 36 ± 2 h post-hCG (pre- or post-ovulation) (ii) the number of IUI (single or double) for pre-ovulatory cases both aims in male, anovulatory and unexplained infertility.

METHODS

The study included a total 1146 first-stimulated cycles in infertile couples due to male factor, anovulation or unexplained infertility. Cycles were stimulated by clomiphine citrate (CC) or sequential CC-hMG or hMG and monitored by transvaginal ultrasound. When the leading follicle reached ≥ 18 mm mean diameter, 10000 IU hCG was given to trigger ovulation and IUI was timed for 36 ± 2 h later. Semen was processed and ovulation was checked at the time of IUI. Post-ovulatory cases received single IUI, while pre-ovulatory cases were sequentially randomized to receive either single or double IUI. The end-point of the cycle was CPR.

RESULTS

Overall CPR in the whole cohort was 10.1%. When ovulation was present before IUI, CPR was 11.7% compared with 6.7% when ovulation was absent [OR (95% CI): 1.85 (1.12-3.06), P = 0.015]. When this OR was computed according to infertility etiology, it was 1.26 (0.52-2.95) (P = 0.82) for male factor infertility and 2.24 (1.23-4.08) (P = 0.007) for non-male factor infertility. Comparing the CPR for double versus single IUI in pre-ovulatory cases, the OR for all cycles was 1.9 (0.76-4.7) (P = 0.22), but according to etiology, it was 4.667 (0.9-24.13) (P = 0.06) in male factor and 1.2 (0.43-3.33) (P = 0.779) for non-male factors.

CONCLUSIONS

Single IUI timed post-ovulation gives a better CPR when compared with single pre-ovulation IUI for non-male infertility, whereas for male factors, pre-ovulation, double IUI gives a better CPR when compared with single IUI.