Pregnancy following treatment with human gonadotropins in primary unexplained infertility

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

OBJECTIVE

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

DESIGN

Observational prospective study.

SETTING

In vitro fertilization embryo transfer center.

PATIENT(S)

Five hundred ninety-four couples with unexplained infertility.

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

Cycle fecundity.

RESULT(S)

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

CONCLUSION(S)

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

The management of unexplained infertility

Unexplained infertility is a diagnosis made by exclusion after all of the standard investigations have revealed no abnormality (1). The range of the prevalence is from 6 to 60 percent (23), depending on the diagnostic criteria. This article reviews the literature in the management of unexplained infertility; published data suggest no benefit of danazol or bromocriptine. The empirical use of clomiphene citrate suggests that ovarian stimulation using clomiphene citrate can double the spontaneous pregnancy rate (52, 58, 59). Induction of ovulation with human menopausal gonadotrophin (hMG) yields an overall pregnancy rate between 2 and 26 percent per cycle (68, 74). These results seem to be lower than those reported for in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) procedures in similar patients (25-30 percent (92, 95)). Based on the literature, a rational treatment plan for treating infertility in couples with unexplained infertility includes up to four cycles of clomiphene citrate with or without intrauterine insemination (IUI). Superovulation with hMG and IUI or stimulated intrauterine insemination (SIUI) is the next step for three-cycle treatments and if unsuccessful, one of the variants of assisted reproductive techniques (ART) should be considered.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will understand the appropriate tests and work up for unexplained infertility, the various treatment options for the unexplained infertility couple including which drugs are effective and not effective, and to be able to outline an appropriate treatment plan for such patients.

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

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

Adrenal response to adrenocorticotropin stimulation in unexplained infertile women

The response to a rapid intravenous administration of adrenocorticotropin (ACTH, cortrosyn) was compared in 24 unexplained infertile women and 13 fertile women. There was no significant difference in the response to a rapid ACTH stimulation as expressed by the slope of testosterone (T) response in both groups. However, the individual and mean T values prior and following the stimulation were significantly higher in the infertile group (P less than 0.001; P less than 0.005, respectively). There was no significant difference in individual values as well as in mean basal values or in mean values of 17-hydroxyprogesterone (17-OHP) after the stimulation between the two study groups (P less than 0.3; P less than 0.9, respectively). There was no significant difference in individual values as well as in mean values of dehydroepiadnrosterone (DHEA) before or 90 min after the stimulation between the two study groups (P less than 0.1; P less than 0.2, respectively). It can therefore be concluded that the elevated basal testosterone values in the infertile group originated from the ovary. Despite the fact that no attempt was made to reduce androgen values 7 (46.66%) of 15 infertile women who were available for follow-up and treatment conceived following ovulation induction therapy.

Human menopausal gonadotropins: a justifiable therapy in ovulatory women with long-standing idiopathic infertility

Long-standing infertility of unknown etiology is currently an indication for in vitro fertilization. Because of the prolonged waiting time, expense, and operative risk, we have treated a group of women with empiric human menopausal gonadotropins/human chorionic gonadotropin before in vitro fertilization. A study group of 97 couples with well-documented, long-standing idiopathic infertility received up to four cycles of empiric human menopausal gonadotropin therapy before in vitro fertilization. This group was compared with a control group of 48 couples who did not receive human menopausal gonadotropin before in vitro fertilization. The 12 (12.4%) conceptions and eight (8.2%) term births resulting from empiric human menopausal gonadotropin therapy in the study group was significantly higher than the number of spontaneous conceptions and births (1%) in the study group (p less than 0.003) and was also greater than the spontaneous conception and birth rate (4%) in the control group (p less than 0.07). The conception rate with empiric human menopausal gonadotropin (12.4%) compared favorably with that after in vitro fertilization (7.9%) and 8 of 12 (66.7%) of empiric human menopausal gonadotropin conceptions resulted in term births, compared with two of seven (28.6%) of the in vitro fertilization conceptions. Preovulatory serum estradiol levels were similar for all study patients undergoing empiric human menopausal gonadotropin therapy, control patients undergoing in vitro fertilization, and patients receiving empiric human menopausal gonadotropin during conception cycles. It therefore appears appropriate to offer a 4-month trial of empiric human menopausal gonadotropin to that specific group of couples with long-standing idiopathic infertility.