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Du T, Xie Q, Qiu J, Zhang S, Mol BW, Zhang S, Kuang Y, Zhao D, Li W. Effect of small follicles on clinical pregnancy and multiple pregnancy rates in intrauterine insemination: a cohort study. Hum Reprod 2024; 39:335-345. [PMID: 38148021 DOI: 10.1093/humrep/dead259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/20/2023] [Indexed: 12/28/2023] Open
Abstract
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.
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Affiliation(s)
- Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin Xie
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaxin Qiu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shiyi Zhang
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, The School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Shaozhen Zhang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong Zhao
- Department of Obstetrics and Gynaecology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wentao Li
- Department of Obstetrics and Gynaecology, The School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- National Perinatal Epidemiology and Statistics Unit (NPESU), Centre for Big Data Research in Health, and School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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Plowden TC, Mumford SL, Wild RA, Cedars MI, Steiner AZ, Franasiak JM, Diamond MP, Santoro N. Probability of Pregnancy With Mono vs Multiple Folliculogenesis in Women With Unexplained Infertility. J Endocr Soc 2022; 7:bvac142. [PMID: 36447958 PMCID: PMC9692188 DOI: 10.1210/jendso/bvac142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Indexed: 12/25/2022] Open
Abstract
Context Ovarian stimulation (OS) increases pregnancy rates but can cause multiple folliculogenesis and multiple pregnancy. Objective To determine whether the probability of pregnancy differs in OS cycles with mono- vs multifolliculogenesis in women with unexplained infertility (UI). Design Secondary analysis of a multicenter, randomized controlled trial: Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation with 3 treatment arms: gonadotropins, clomiphene, or letrozole, combined with intrauterine insemination. Women were categorized as having either 1 or ≥ 2 mature follicles (≥ 16 mm). Relative risk (RR) and 95% CIs for clinical pregnancy and live birth by number of follicles were estimated using generalized linear models adjusted for age, body mass index, years of infertility, and history of prior live birth. Setting 12 US-based clinical sites. Participants Normally cycling women aged 18 to 40 years with a normal uterine cavity and at least 1 patent fallopian tube. Male partners with ≥ 5 million total motile sperm. Interventions Gonadotropins, clomiphene, or letrozole with insemination. Main Outcome Measures Clinical pregnancy rates (CPR) and live birth rates (LBR). Results A single mature follicle > 16 mm resulted in lower CPR (RR, 0.70; 95% CI, 0.54-0.90) and LBR (RR, 0.67; 95% CI, 0.51-0.89) compared with ≥ 2 mature follicles. When stratified by treatment modality, no association of follicle number with CPR or LBR was observed for letrozole or clomiphene, but women using gonadotropins had lower CPR and LBR with monofolliculogenesis. Conclusion In couples undergoing gonadotropin treatment for UI, monofolliculogenesis following OS is related to a lower rate of live birth.
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Affiliation(s)
- Torie C Plowden
- Correspondence: Torie Comeaux Plowden, MD, Department of Gynecologic Surgery and Obstetrics, 2817 Reilly Road, Fort Bragg, NC 28310.
| | - Sunni L Mumford
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD 20892, USA
| | - Robert A Wild
- Department of Obstetrics and Gynecology, OUHSC, Oklahoma City, OK 73117, USA
| | - Marcelle I Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94158, CA, USA
| | | | - Jason M Franasiak
- RMA New Jersey, Thomas Jefferson University, Basking Ridge, NJ 07920, USA
| | | | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Marin L, Andrisani A, Bordin L, Dessole F, Noventa M, Vitagliano A, Capobianco G, Ambrosini G. Sildenafil Supplementation for Women Undergoing Infertility Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:4346. [PMID: 34640363 DOI: 10.3390/jcm10194346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/14/2022] Open
Abstract
The aim of this systematic review and meta-analysis is to summarize data on the effectiveness of Sildenafil supplementation for women undergoing assisted reproduction techniques. This meta-analysis of randomized controlled trials (RCTs) evaluates the effects of Sildenafil administration during infertility treatments compared with a control group in infertile women. Outcomes evaluated were endometrial thickness (ETh) and the clinical pregnancy rate (CPR). The chemical pregnancy rate (ChPR) was also evaluated. Pooled results were expressed as the risk ratio (RR) or mean differences (MD) with a 95% confidence interval (95% CI). Women undergoing ovulation induction who received Sildenafil showed higher ETh and a higher CPR in comparison to controls. In this group, both the ETh and ChPR resulted in significantly higher values only with delayed start administration. Women undergoing fresh or frozen embryo transfer who received Sildenafil showed no significant advantages regarding ETh and CPR in comparison to controls. In this group, we found a significantly higher ChPR in women receiving Sildenafil. A subgroup analysis revealed significant advantages regarding ETh with oral administration for women undergoing fresh or frozen embryo transfer. Sildenafil therapy appears to improve endometrial thickness and pregnancy rate in women undergoing timed intercourses but it resulted not effective in IUI and IVF treatments. Further RCTs with rigorous methodology are still mandatory.
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Tokgoz VY, Sukur YE, Ozmen B, Sonmezer M, Berker B, Aytac R, Atabekoglu CS. Clomiphene Citrate versus Recombinant FSH in intrauterine insemination cycles with mono- or bi-follicular development. JBRA Assist Reprod 2021; 25:383-389. [PMID: 33746515 PMCID: PMC8312288 DOI: 10.5935/1518-0557.20200106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: The present study aims to assess the success of controlled ovarian stimulation in intrauterine insemination cycles stimulated by recombinant-FSH and Clomiphene citrate for either mono- or bi-follicular development. Methods: We assessed 870 infertile patients treated with controlled ovarian stimulation in intrauterine insemination cycles at a university-based infertility clinic between January 2012 and December 2017. We compared the cycles stimulated by clomiphene citrate and recombinant-FSH in two set-ups; mono- and bi-follicular development. The main outcome measure was the clinical pregnancy rate per cycle. Results: The demographic and cycle parameters were similar between the groups, except for endometrial thickness on the day of hCG administration, which was higher in the recombinant-FSH group than the clomiphene citrate group. The overall clinical pregnancy rates in clomiphene citrate and recombinant-FSH groups were 9.8% and 10.3%, respectively (p=0.940). Regarding the entire cohort, clinical pregnancy was significantly higher in cases of bi-follicular development when compared to mono-follicular development (16.8% vs. 10.2%, respectively; p=0.009). Conclusions: Clomiphene citrate and recombinant-FSH have similar success rates in terms of clinical pregnancy, in either mono-follicular development or bi-follicular development. Clomiphene citrate and recombinant-FSH cycles resulted in comparable rates of bi-follicular development, which significantly increases clinical pregnancy rate. Clomiphene citrate and recombinant-FSH have similar success rates in terms of clinical pregnancy, in either mono-follicular development or bi-follicular development.
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Affiliation(s)
- Vehbi Yavuz Tokgoz
- Department of Obstetrics and Gynecology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Yavuz Emre Sukur
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Batuhan Ozmen
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Murat Sonmezer
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Bulent Berker
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Rusen Aytac
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Cem Somer Atabekoglu
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
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Practice Committees of the American Society for Reproductive Medicine and Society for Reproductive Endocrinology and Infertility. Electronic address: asrm@asrm.org. Use of exogenous gonadotropins for ovulation induction in anovulatory women: a committee opinion. Fertil Steril 2020; 113:66-70. [PMID: 32033726 DOI: 10.1016/j.fertnstert.2019.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022]
Abstract
This document reviews gonadotropin treatment for ovulation induction in anovulatory women and outlines the recommended pretreatment evaluation, indications, treatment regimens, and complications of gonadotropin treatment. It replaces the document with a similar name, last published in 2008 (Fertil Steril 2008;90:S7-12).
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Evans MB, Stentz NC, Richter KS, Schexnayder B, Connell M, Devine K, Widra E, Healy MW, Stillman R, DeCherney AH, Hill MJ. Mature Follicle Count and Multiple Gestation Risk Based on Patient Age in Intrauterine Insemination Cycles With Ovarian Stimulation. Obstet Gynecol 2020; 135:1005-1014. [PMID: 32282611 PMCID: PMC7183886 DOI: 10.1097/aog.0000000000003795] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the risk of a multiple gestation pregnancy in ovarian stimulation intrauterine insemination (IUI) cycles when stratified by patient age and mature follicle number. METHODS We conducted a retrospective cohort study at a single private practice fertility center of IUI cycles performed from 2004 to 2017. Intervention(s) were ovarian stimulation and IUI if postwash total motile sperm count was more than 8 million. Mature follicles were defined as 14 mm or more as measured on the day of ovulation trigger. Main outcomes and measures were rates of clinical pregnancy and multiple gestation. RESULTS We identified 24,649 women who underwent a total of 50,473 IUI cycles. Increasing the number of mature follicles from one to five at the time of IUI in women younger than age 38 years increased the clinical pregnancy rate from 14.6% to 21.9% (adjusted odds ratio [aOR] 1.6, 95% CI 1.4-1.9), almost entirely from a marked increase in multiple gestations per cycle from 0.6% to 6.5% (aOR 9.9, 95% CI 6.9-14.2). There was little increase in singleton pregnancies per IUI (14.1-16.4%) regardless of mature follicle number. The per-pregnancy twin and higher-order multiple gestation risk significantly increased (3.9-23.3%, P<.01 and 0.2-10.6%, P<.01, respectively) when comparing one with five mature follicles present at the time of IUI (P<.01). In women younger than age 38 years with more than three follicles present, more than one quarter of all pregnancies were multiples. Similar findings occurred in women aged 38-40 years. In women older than age 40 years, up to four follicles tripled the odds of pregnancy (aOR 3.1, 95% CI 2.1-4.5) while maintaining a less than 12% risk of multiple gestation per pregnancy and a 1.0% absolute risk of multiples. CONCLUSION Caution should be used in proceeding with IUI after ovarian stimulation when there are more than two mature follicles in women younger than age 40 years owing to the substantially increased risk of multiple gestation without an improved chance of singleton clinical pregnancy.
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Affiliation(s)
- M. Blake Evans
- Program in Reproductive Endocrinology and Gynecology,
Eunice Kennedy Shriver National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | | - Eric Widra
- Shady Grove Fertility Center, Rockville, MD
| | - Mae W. Healy
- Program in Reproductive Endocrinology and Gynecology,
Eunice Kennedy Shriver National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland
| | | | - Alan H. DeCherney
- Program in Reproductive Endocrinology and Gynecology,
Eunice Kennedy Shriver National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland
| | - Micah J. Hill
- Program in Reproductive Endocrinology and Gynecology,
Eunice Kennedy Shriver National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland
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Bouknight JM. Too Much of a Good Thing: Multiple Gestations With Intrauterine Insemination. Obstet Gynecol 2020; 135:1003-4. [PMID: 32282590 DOI: 10.1097/AOG.0000000000003849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ejzenberg D, Gomes TJ, Monteleone PA, Serafini PC, Soares‐Jr JM, Baracat EC. Prognostic factors for pregnancy after intrauterine insemination. Int J Gynaecol Obstet 2019; 147:65-72. [DOI: 10.1002/ijgo.12898] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 10/14/2018] [Accepted: 06/25/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Dani Ejzenberg
- Disciplina de GinecologiaDepartamento de Obstetrícia e GinecologiaHospital das ClínicasFaculdade de Medicina São Paulo Brazil
| | - Tiago J.O. Gomes
- Disciplina de GinecologiaDepartamento de Obstetrícia e GinecologiaHospital das ClínicasFaculdade de Medicina São Paulo Brazil
| | - Pedro A.A. Monteleone
- Disciplina de GinecologiaDepartamento de Obstetrícia e GinecologiaHospital das ClínicasFaculdade de Medicina São Paulo Brazil
| | - Paulo C. Serafini
- Disciplina de GinecologiaDepartamento de Obstetrícia e GinecologiaHospital das ClínicasFaculdade de Medicina São Paulo Brazil
| | - José M. Soares‐Jr
- Disciplina de GinecologiaDepartamento de Obstetrícia e GinecologiaHospital das ClínicasFaculdade de Medicina São Paulo Brazil
| | - Edmund C. Baracat
- Disciplina de GinecologiaDepartamento de Obstetrícia e GinecologiaHospital das ClínicasFaculdade de Medicina São Paulo Brazil
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Sun T, Lee B, Kinchen J, Wang ET, Gonzalez TL, Chan JL, Rotter JI, Chen YDI, Taylor K, Goodarzi MO, Rich SS, Farber CR, Williams J, Pisarska MD. Differences in First-Trimester Maternal Metabolomic Profiles in Pregnancies Conceived From Fertility Treatments. J Clin Endocrinol Metab 2019; 104:1005-1019. [PMID: 30445606 PMCID: PMC6373171 DOI: 10.1210/jc.2018-01118] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 11/12/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Maternal metabolic status reflects underlying physiological changes in the maternal-placental-fetal unit that may help identify contributors to adverse pregnancy outcomes associated with infertility and treatments used. OBJECTIVE To determine if maternal metabolomic profiles differ between spontaneous pregnancies and pregnancies conceived with fertility treatments that may explain the differences in pregnancy outcomes. DESIGN Metabolon metabolomic analysis and ELISAs for 17-β-estradiol and progesterone were performed during the late first trimester of pregnancy. SETTING Academic institution. SUBJECTS Women in the Spontaneous/Medically Assisted/Assisted Reproductive Technology cohort (N = 409), 208 of whom conceived spontaneously and 201 with infertility [non in vitro fertilization treatments (NIFT), n=90; in vitro fertilization (IVF), n=111]. INTERVENTION Mode of conception. MAIN OUTCOME MEASURES Levels of of 806 metabolites within eight superpathways, 17-β-estradiol, and progesterone in maternal plasma in the late first trimester. RESULTS Metabolomic differences in the lipid superpathway (i.e., steroid metabolites, lipids with docosahexaenoyl acyl chains, acyl cholines), and xanthine and benzoate metabolites (P < 0.05) were significant among the spontaneous and two infertility groups, with greatest differences between the spontaneous and IVF groups. 17-β-estradiol and progesterone levels were significantly elevated in the infertility groups, with greatest differences between the spontaneous and IVF groups. CONCLUSION Metabolomic profiles differ between spontaneous and infertility pregnancies, likely driven by IVF. Higher levels of steroids and their metabolites are likely due to increased hormone production from placenta reprogrammed from fertility treatments, which may contribute to adverse outcomes associated with infertility and the treatments used.
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Affiliation(s)
- Tianyanxin Sun
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bora Lee
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Erica T Wang
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Tania L Gonzalez
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jessica L Chan
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jerome I Rotter
- LA Biomed/Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Yii-Der Ida Chen
- LA Biomed/Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Kent Taylor
- LA Biomed/Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Mark O Goodarzi
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia
| | - Charles R Farber
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia
| | - John Williams
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Margareta D Pisarska
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Correspondence and Reprint Requests: Margareta D. Pisarska, MD, Cedars-Sinai Medical Center, 8635 West Third Street, Suite 160, Los Angeles, California 90048. E-mail:
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Giles J, Cruz M, González-Ravina C, Caligara C, Prados N, Martínez JC, Vergara V, Requena A. Small-sized follicles could contribute to high-order multiple pregnancies: outcomes of 6552 intrauterine insemination cycles. Reprod Biomed Online 2018; 37:549-554. [PMID: 30482725 DOI: 10.1016/j.rbmo.2018.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 11/17/2022]
Abstract
RESEARCH QUESTION Can predictors of twin and high-order multiple pregnancy among women with multiple cycles of ovarian stimulation intrauterine insemination (IUI) be identified? DESIGN Retrospective cohort study of IUI cycles carried out between January 2014 and December 2015 in a private clinic in Spain. The 4879 women and 6552 cycles analysed in this study include single IUI with ovarian stimulation using recombinant FSH. RESULTS Number of follicles and follicle size were the only factors with a significant effect (P < 0.001) on the likelihood of achieving a twin or multifetal pregnancy. Follicles 12 mm or wider greatly increase the chances of achieving a twin or multifetal pregnancy. A total of 73 out of 127 (57.5%) twin pregnancies occurred in cycles with at least one additional follicle measuring 12 mm or wider, and 102 out of 127 twin pregnancies (80.3%) occurred in cycles with at least one additional follicle measuring 14 mm or wider. Cancellation criteria should consider the presence of follicles 12 mm or wider. CONCLUSION Follicles measuring 12 mm or wider increase the risk of having a twin or a high-order multiple pregnancy rate. These data may help clinicians balance decision-making between cancelling and performing the cycle within an IUI procedure.
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Affiliation(s)
- J Giles
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Valencia, Plaza de la Policía Local 3, Valencia 46015, Spain.
| | - M Cruz
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023
| | - C González-Ravina
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, Sevilla 41011, Spain
| | - C Caligara
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, Sevilla 41011, Spain
| | - N Prados
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, Sevilla 41011, Spain
| | - J C Martínez
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad (IVI) Murcia, Calle Navegante Macías del Poyo, 5 - Edificio Delfín - Barrio La Flota, Murcia 30007, Spain
| | - V Vergara
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023
| | - A Requena
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023
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11
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Huang Q, Niu Y, Xu L, Chen B, Zhang Y, Song LJ, Jing X, Wei B, Ma T. Relationship between a low ratio of serum estradiol to follicle number and fertility treatment outcomes: A retrospective cohort study of 516 cases. Medicine (Baltimore) 2018; 97:e12017. [PMID: 30142848 PMCID: PMC6112930 DOI: 10.1097/md.0000000000012017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022] Open
Abstract
The aim of this retrospective study was to examine how a low estradiol/follicle (E2/fol) may be related to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI)-embryo transfer outcomes in polycystic ovary syndrome (PCOS) and non-PCOS patients, respectively. Between 2013 and 2017, 516 IVF/ICSI cycles (146 cycles in PCOS patients and 370 cycles in non-PCOS patients) with a long gonadotrophin releasing hormone receptor agonist protocol-including 338 involved fresh transfer cycles (89 cycles in PCOS patients and 249 cycles in non-PCOS patients)-were conducted. Outcomes were compared between 5 groups of PCOS patients defined by E2/fol (pg/mL) as follows: A, <140; B, 140 to 210; C, 210 to 280; D, 280 to 350; and E, >350. Non-PCOS patients' outcomes are grouped as well. Whether in PCOS or non-PCOS patients, those in the lowest E2/fol group (<140 pg/mL) tended to be younger, and with a greater body mass index (BMI) and antral follicle count (AFC), than the patients in the other groups. Relative to the other groups, Group A showed a lower number and rate of oocytes, higher single pronucleus (1PN) and triple pronucleus (3PN) formation rate, early and advanced abortion rates, but these did not differ significantly from those of the other groups, it perhaps due to the limited sample size. Group A have a higher incidence of moderate or severe ovarian hyperstimulation syndrome than the other groups in non-PCOS patients (P > .05). Whether in PCOS or non-PCOS patients, greater BMI, greater AFC, and younger age may favor the phenomenon of low E2/fol. In turn, low E2/fol may reduce the oocyte retrieval rate and increase the risk of 1PN and 3PN formation and abortion.
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Affiliation(s)
- Qiaoyao Huang
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Yanru Niu
- Laboratory of Minimally Invasive Orthopedics, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Lihua Xu
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Bi Chen
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Yunshan Zhang
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Li Jun Song
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Xia Jing
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Bing Wei
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
| | - Tianzhong Ma
- Reproductive Medicine Center, Affiliated Hospital of Guangdong Medical University
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Sun XJ, Jiang L, Ji LC, Nie R, Chen H, Jin L, Zhu GJ, Qian K. A retrospective analysis of ovarian stimulation with letrozole in women undergoing artificial insemination by donor. Reprod Biomed Online 2017; 34:354-360. [PMID: 28187961 DOI: 10.1016/j.rbmo.2017.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 01/07/2017] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
The aim of this retrospective study was to determine the clinical pregnancy rate in women undergoing letrozole ovarian stimulation and artificial insemination by donor (AID). Between 2012 and 2015, 130 natural cycles, 939 letrozole cycles and 130 letrozole plus gonadotrophin cycles were conducted. Letrozole cycles were divided into three groups according to LH concentration on the day of HCG administration (LH <10 mIU/ml and follicle size ≥18 cm; LH ≤10 to <20 mIU/ml; and LH ≥20 mIU/ml). Pregnancy rates were 17.3%, 22.4% and 26.8%, respectively (P = 0.012). In women given 10 mIU/ml LH or more, logistic regression identified oestradiol (OR 1.002, 95% CI, 1.000 to 1.004, P = 0.029) and leading follicle size (OR 0.861, 95% CI, 0.772 to 0.960, P = 0.007) as significant predictive factors of pregnancy rate; the higher the oestradiol and the smaller the follicles, the better the pregnancy rate. The pregnancy rate was significantly higher in the letrozole plus gonadotrophin group than the letrozole group (P = 0.04). Better pregnancy rates can be achieved if LH surge occurs before HCG administration, especially with higher oestradiol and lower follicle size; treatment with letrozole plus gonadotrophin was significantly more effective than letrozole alone in AID.
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Affiliation(s)
- X J Sun
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - L Jiang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - L C Ji
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - R Nie
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - H Chen
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - L Jin
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China.
| | - G J Zhu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China.
| | - K Qian
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China.
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Lee B, Kroener LL, Xu N, Wang ET, Banks A, Williams J, Goodarzi MO, Chen YDI, Tang J, Wang Y, Gangalapudi V, Pisarska MD. Function and Hormonal Regulation of GATA3 in Human First Trimester Placentation. Biol Reprod 2016; 95:113. [PMID: 27733378 PMCID: PMC5178150 DOI: 10.1095/biolreprod.116.141861] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/01/2016] [Accepted: 09/30/2016] [Indexed: 12/23/2022] Open
Abstract
Pregnancies resulting from fresh in vitro fertilization (IVF) cycles exposed to supraphysiologic estrogen levels have been associated with higher rates of low birth weight and small for gestational age babies. We identified GATA3, a transcription factor selectively expressed in the trophectoderm during the blastocyst stage of embryo development, in an upstream analysis of genes that were differentially methylated in chorionic villus samples between IVF and non-IVF infertility treatment pregnancies. In this study, we investigate the hypothesis that GATA3 is hormonally regulated and plays an important functional role in trophoblast migration, invasion, and placentation. We found that GATA3 expression was hormonally regulated by estradiol in HTR8/SVneo first trimester trophoblast cells; however, no change in expression was seen with progesterone treatment. Furthermore, GATA3 knockdown resulted in decreased HTR8/SVneo cell migration and invasion compared with controls. RNA sequencing of GATA3 knockdown cells demonstrated 96 differentially regulated genes compared with controls. Genes known to play an important role in cell-cell and cell-extracellular matrix interactions, cell invasion, and placentation were identified, including CTGF, CYR61, ADAMTS12, and TIMP3. Our results demonstrate estradiol down-regulates GATA3, and decreased GATA3 expression leads to impaired trophoblast cell migration and invasion, likely through regulation of downstream genes important in placentation. These results are consistent with clinical data suggesting that supraphysiologic estrogen levels seen in IVF pregnancies may play an important role in attenuated trophoblast migration, invasion, and impaired placentation. GATA3 appears to be an important regulator of placentation and may play a role in impaired outcomes associated with fresh IVF cycles.
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Affiliation(s)
- Bora Lee
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lindsay L Kroener
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.,UCLA School of Medicine, Los Angeles, California
| | - Ning Xu
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Erica T Wang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.,UCLA School of Medicine, Los Angeles, California
| | - Alexandra Banks
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - John Williams
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai-Medical Center, Los Angeles, California
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yii-der I Chen
- Institute for Translational Genomics and Population Sciences, LABiomed/Harbor-UCLA Medical Center, Torrance, California
| | - Jie Tang
- Genomics Core, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yizhou Wang
- Genomics Core, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Margareta D Pisarska
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California .,UCLA School of Medicine, Los Angeles, California
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Erdem M, Abay S, Erdem A, Firat Mutlu M, Nas E, Mutlu I, Oktem M. Recombinant FSH increases live birth rates as compared to clomiphene citrate in intrauterine insemination cycles in couples with subfertility: a prospective randomized study. Eur J Obstet Gynecol Reprod Biol 2015; 189:33-7. [DOI: 10.1016/j.ejogrb.2015.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/18/2015] [Accepted: 03/19/2015] [Indexed: 11/16/2022]
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Goldman MB, Thornton KL, Ryley D, Alper MM, Fung JL, Hornstein MD, Reindollar RH. A randomized clinical trial to determine optimal infertility treatment in older couples: the Forty and Over Treatment Trial (FORT-T). Fertil Steril 2014; 101:1574-81.e1-2. [PMID: 24796764 DOI: 10.1016/j.fertnstert.2014.03.012] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/05/2014] [Accepted: 03/05/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the optimal infertility therapy for women at the end of their reproductive potential. DESIGN Randomized clinical trial. SETTING Academic medical centers and private infertility center in a state with mandated insurance coverage. PATIENT(S) Couples with ≥ 6 months of unexplained infertility; female partner aged 38-42 years. INTERVENTION(S) Randomized to treatment with two cycles of clomiphene citrate (CC) and intrauterine insemination (IUI), follicle stimulating hormone (FSH)/IUI, or immediate IVF, followed by IVF if not pregnant. MAIN OUTCOME MEASURE(S) Proportion with a clinically recognized pregnancy, number of treatment cycles, and time to conception after two treatment cycles and at the end of treatment. RESULT(S) We randomized 154 couples to receive CC/IUI (N = 51), FSH/IUI (N = 52), or immediate IVF (N = 51); 140 (90.9%) couples initiated treatment. The cumulative clinical pregnancy rates per couple after the first two cycles of CC/IUI, FSH/IUI, or immediate IVF were 21.6%, 17.3%, and 49.0%, respectively. After all treatments, 110 (71.4%) of 154 couples had conceived a clinically recognized pregnancy, and 46.1% had delivered at least one live-born baby; 84.2% of all live-born infants resulting from treatment were achieved via IVF. There were 36% fewer treatment cycles in the IVF arm compared with either COH/IUI arm, and the couples conceived a pregnancy leading to a live birth after fewer treatment cycles. CONCLUSION(S) A randomized controlled trial in older women with unexplained infertility to compare treatment initiated with two cycles of controlled ovarian hyperstimulation/IUI versus immediate IVF demonstrated superior pregnancy rates with fewer treatment cycles in the immediate IVF group. CLINICAL TRIAL REGISTRATION NUMBER NCT00246506.
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Affiliation(s)
- Marlene B Goldman
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Community and Family Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | | | | | | | - June L Fung
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mark D Hornstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard H Reindollar
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; American Society for Reproductive Medicine, Birmingham, Alabama
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Chiwanga ES, Massenga G, Mlay P, Obure J, Mahande MJ. Maternal outcome in multiple versus singleton pregnancies in Northern Tanzania: A registry-based case control study. Asian Pacific Journal of Reproduction 2014. [DOI: 10.1016/s2305-0500(14)60001-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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da Silva ALB, Arbo E, Fanchin R. Early versus late hCG administration to trigger ovulation in mild stimulated IUI cycles: a randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2012; 164:156-60. [DOI: 10.1016/j.ejogrb.2012.05.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 05/04/2012] [Accepted: 05/27/2012] [Indexed: 11/28/2022]
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McClamrock HD, Jones HW, Adashi EY. Ovarian stimulation and intrauterine insemination at the quarter centennial: implications for the multiple births epidemic. Fertil Steril 2012; 97:802-9. [PMID: 22463774 DOI: 10.1016/j.fertnstert.2012.02.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 11/26/2022]
Abstract
Ovarian stimulation and intrauterine insemination (OS/IUI), a mainstay of current infertility therapy and a common antecedent to IVF, is a significant driver of the multiple births epidemic. Redress of this challenge, now marking its quarter centennial, will require a rethinking of current practice patterns. Herein we explore prospects for prevention, mitigation, and eventual resolution. We conclude that the multiple births attributable to OS/IUI may not be entirely preventable but that the outlook for their mitigation is promising, if in need of solidification. Specifically, we observe that low-dose (≤ 75 IU) gondotropin, clomiphene, and especially off-label letrozole regimens outperform high-dose (≥ 150 IU) gonadotropin counterparts in the gestational plurality category while maintaining comparable per-cycle pregnancy rates. Accordingly we recommend that, subject to appropriate exceptions, high-dose gonadotropin regimens be used sparingly and that whenever possible they be replaced with emerging alternatives. Finally, we posit that OS/IUI is not likely to be superseded by IVF absent further commoditization and thus greater affordability.
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Fong SA, Palta V, Oh C, Cho MM, Loughlin JS, McGovern PG. Multiple pregnancy after gonadotropin-intrauterine insemination: an unavoidable event? ISRN Obstet Gynecol 2011; 2011:465483. [PMID: 22254142 PMCID: PMC3255317 DOI: 10.5402/2011/465483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 11/20/2011] [Indexed: 11/23/2022]
Abstract
Objective. Determine which factors predict multiple pregnancy in gonadotropin-intrauterine insemination cycles so that cancellation criteria might be developed. Study Design. Retrospective chart review of all patients undergoing gonadotropin-intrauterine insemination over a continuous 36 month period. Results. No factors examined were able to predict the occurrence of multiple pregnancy. Conclusion. Multiple pregnancy is an unavoidable complication of gonadotropin-intrauterine insemination treatment.
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Affiliation(s)
- Shirley A. Fong
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Vidya Palta
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Cheongeun Oh
- Division of Biostatistics, New York University School of Medicine, 650 First Avenue Room 556/558, New York, NY 10016, USA
| | - Michael M. Cho
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Jacquelyn S. Loughlin
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Peter G. McGovern
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
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Sarhan A, Beydoun H, Jones HW, Bocca S, Oehninger S, Stadtmauer L. Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles. Reprod Biomed Online 2011; 23:220-6. [PMID: 21665547 DOI: 10.1016/j.rbmo.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
Ovulation induction (OI) or ovulation enhancement (OE) with gonadotrophins can be a reasonable treatment option for patients with a variety of infertility diagnoses. It must be used with extensive monitoring and management given the risk of multiple pregnancy,especially high-order multiples. This retrospective study evaluated per cycle outcomes of a large cohort of 1452 gonadotrophin OI/OE cycles at an academic infertility centre, and the efficacy of specific guidelines in limiting multiple pregnancy. The lowest possible gonadotrophin doses were used and cycle cancellation was recommended if more than three dominant follicles were present, and/or ifserum oestradiol was above 1500 pg/ml. Overall, pregnancy rate (PR) was 12% and live birth rate was 7.7%, with an increasing trend in younger patients (P = 0.0002 and <0.0001, respectively). Multiple clinical PR was 2.6% with 1.9% twins and 0.7% triplets and above.The birthweight of a singleton from a vanishing twin pregnancy (n = 8)was significantly lower than other singletons (2882 g versus 3250 g,P = 0.013). Reducing multiple pregnancies from OI/OE cycles remains an important and challenging goal. In this large cohort, high-order multiple clinical PR was limited to 0.7% per cycle by using specific management strategies while maintaining a reasonable PR.
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Affiliation(s)
- Abbaa Sarhan
- The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA.
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Reindollar RH, Regan MM, Neumann PJ, Levine BS, Thornton KL, Alper MM, Goldman MB. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril 2010; 94:888-99. [DOI: 10.1016/j.fertnstert.2009.04.022] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 04/07/2009] [Accepted: 04/08/2009] [Indexed: 10/20/2022]
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Cédrin-Durnerin I, Belaisch-Allart J, Avril C, Pouly JL. [Predictive factors of success in ovulation induction with recombinant FSH: results of Indigo study]. Gynecol Obstet Fertil 2010; 38:105-113. [PMID: 20106707 DOI: 10.1016/j.gyobfe.2009.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 12/14/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Although ovulation induction is commonly used to treat infertility, few data are available concerning this treatment. Therefore, the aim of this prospective observational study was to describe medical practices and to identify predictive outcome factors of ovarian stimulation by recombinant FSH (r-hFSH), administrated with a self-injector pen. PATIENTS AND METHODS At the time of the prescription of ovarian stimulation followed by sexual intercourse (SI) or artificial insemination (HAI) with a normal husband sperm, 370 gynaecologists consecutively sent from January to November 2005, for a maximum of six patients (1398 patients in total), a form dealing with the assessment of infertility factors prior to stimulation (n=1340), then a monitoring form of the treated cycle (n=1227) and when a pregnancy was obtained, a follow-up form at 12 weeks of amenorrhea (n=254). Each patient had to complete an autoquestionnaire about the use of the pen (n=1044). RESULTS Seventy percent of the contributing gynaecologists had only a private practice. The mean age of patients was 31.9+/-4.8 years. Dealing with infertility exploration prior to stimulation, 9% did not have tubal assessment. Although it was the first stimulation attempt for 52% of cases, 91% of patients found the pen easy to manipulate. The mean duration of r-hFSH administration was 8.8+/-3.7 days and the mean daily dose was 75.4+/-29.4 IU. Ultrasound and hormonal monitoring was performed for 88% of patients. The cycle cancellation rate was 11%. The hCG administration was performed on cycle day 13+/-3. An HAI was programmed in 60% of patients and SI in 40%. The pregnancy rates for positive betahCG, ongoing and multiple pregnancies were, respectively, 22.7, 18 and 16% (twins 14%; 2% of triplets or more 2%). Three prognosis factors were independently related to ongoing pregnancy rate: age<35 years, previous pregnancy obtained by treatment and presence of ovulatory disorders. DISCUSSION AND CONCLUSION This observatory of ovarian stimulation out of FIV allowed to describe medical practices of gynaecologists: infertility assessment prior to ovarian stimulation, used FSH doses, ultrasound and hormonal monitoring, and it outlined three predictive factors of outcome: age, previous pregnancy obtained by treatment and presence of ovulatory disorders.
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Affiliation(s)
- I Cédrin-Durnerin
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France.
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Abstract
A commentary on contributions of ART to the pandemic of multiple gestations is presented and mechanistic aspects therein are explored.
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Affiliation(s)
- Monica Kapoor
- Department of Obstetrics & Gynecology, Danbury Hospital, Danbury, Connecticut, USA
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Haim D, Leniaud L, Porcher R, Martin-Pont B, Wolf JP, Sifer C. Évaluation prospective de l’impact des paramètres spermatiques sur le succès des inséminations intra-utérines. ACTA ACUST UNITED AC 2009; 37:229-35. [DOI: 10.1016/j.gyobfe.2008.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 09/22/2008] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence. DESIGN Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented. RESULT(S) High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles. CONCLUSION(S) High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.
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Affiliation(s)
- Richard Palmer Dickey
- Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, The Fertility Institute of New Orleans, New Orleans, Louisiana, USA.
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van Rumste M, Custers I, van der Veen F, van Wely M, Evers J, Mol B. The influence of the number of follicles on pregnancy rates in intrauterine insemination with ovarian stimulation: a meta-analysis. Hum Reprod Update 2008; 14:563-70. [DOI: 10.1093/humupd/dmn034] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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de la Cuesta Benjumea R, Tasende Areosa M, Ángeles Martos Cano M, Iglesias Goy E. Análisis de los factores de influencia sobre el resultado de 500 ciclos de inseminación intrauterina homóloga. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s0304-5013(08)71058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ghesquiere SL, Castelain EG, Spiessens C, Meuleman CL, D’Hooghe TM. Relationship between follicle number and (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination. Am J Obstet Gynecol 2007; 197:589.e1-5. [PMID: 18060945 DOI: 10.1016/j.ajog.2007.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 03/04/2007] [Accepted: 05/11/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The goal of this study was to determine the relationship between the number of mature ovarian follicles and the (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination. STUDY DESIGN A total of 2463 intrauterine insemination cycles performed during a natural cycle (n = 118), or after controlled ovarian hyperstimulation with either clomiphene citrate (n = 663) or with gonadotrophins (n = 1682) were reviewed to assess the impact of the type of stimulation and the number of follicles 14 mm or larger on the (multiple) live birth rate per cycle. RESULTS The live birth rate after intrauterine insemination was significantly higher (P = .02) after stimulation with gonadotrophins (13%) than after clomiphene cirate (8%) if only 1 follicle 14 mm or larger was present. If 2 or more follicles were present, there was no statistically significant difference between both stimulation methods. CONCLUSION Treatment of intrauterine insemination with gonadotrophin is effective with an acceptable (multiple) live birth rate when 1 or 2 follicles 14 mm or larger are present.
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Gómez-Palomares JL, Acevedo-Martín B, Chávez M, Manzanares MA, Ricciarelli E, Hernández ER. Multifollicular recruitment in combination with gonadotropin-releasing hormone antagonist increased pregnancy rates in intrauterine insemination cycles. Fertil Steril 2007; 89:620-4. [PMID: 17678911 DOI: 10.1016/j.fertnstert.2007.03.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 03/12/2007] [Accepted: 03/12/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether including a GnRH antagonist in controlled ovarian stimulation-intrauterine insemination cycles would increase pregnancy rates. DESIGN Prospective randomized study. SETTING Private reproductive medicine clinic in Spain. PATIENT(S) Three hundred sixty-seven women with primary or secondary infertility. INTERVENTION(S) Patients were randomly assigned to controlled ovarian stimulation with recombinant FSH (75-150 IU/d) alone (controls, n = 183) or with recombinant FSH (75-150 IU/d) + the GnRH antagonist (0.25 mg/d), initiated when the recruited follicles were >or=16 mm (n = 184). A single insemination was performed, 36-38 hours after hCG (5,000 IU, IM), in both groups. MAIN OUTCOME MEASURE(S) Follicular recruitment, pregnancy rates. RESULT(S) Numbers of mature follicles (2.4 +/- 1.3 vs. 1.3 +/- 1.09) and clinical pregnancy rates (23% vs. 11%) were statistically significantly higher in patients who were treated with GnRH antagonist than in those who were in the control group. The pregnancy rate was only higher in the antagonist group if more than one follicle sized >or=18 mm was present on the day that the hCG was given. A similar number of twin pregnancies occurred in both groups: two in the antagonist group and three in the control group. The antagonist group also had one triplet gestation. CONCLUSION(S) Adding GnRH antagonist to controlled ovarian stimulation-intrauterine insemination cycles significantly increases pregnancy rates in multifollicular, but not monofollicular, cycles.
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Park SJ, Alvarez JR, Weiss G, Von Hagen S, Smith D, McGovern PG. Ovulatory status and follicular response predict success of clomiphene citrate-intrauterine insemination. Fertil Steril 2007; 87:1102-7. [PMID: 17261288 DOI: 10.1016/j.fertnstert.2006.11.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2006] [Revised: 11/09/2006] [Accepted: 11/09/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the hypothesis that anovulatory women would have good pregnancy rates (PRs), regardless of single or multiple follicular development, in response to clomiphene citrate (CC), whereas ovulatory women would have good PRs only when achieving multifollicular responses to CC. DESIGN Retrospective chart review. SETTING University-based infertility center. PATIENT(S) Two hundred and fifty-four women underwent 585 CC-IUI treatment cycles over a 3-year period. INTERVENTION Treatment with CC-IUI. MAIN OUTCOME MEASURE(S) Various factors were examined as predictors of clinical pregnancy rate (CPR) and live-birth rate (LBR) per cycle with the use of logistic regression. RESULT(S) Overall, the CPR was 11.1%, and the LBR was 8.7%. Of 65 clinical pregnancies, 81.5% resulted in live births (singletons, 67.7%; twins, 13.8%). There were no higher-order deliveries. In anovulatory women, the CPR and LBR were 15.7% and 13.6%, respectively. In ovulatory women, the CPR and LBR were 8.8% and 6.3%, respectively. As the number of large follicles increased from one to two, the LBR increased from 6.8% to 10.5%. Regarding the interaction of follicles with ovulatory status, anovulatory women had nearly double the CPR and LBR compared to those in ovulatory women, irrespective of the number of large follicles. CONCLUSION(S) Treatment with CC-IUI is more successful in anovulatory women than in ovulatory women. The multiple follicular response in both ovulatory and anovulatory women increases PRs.
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Affiliation(s)
- Susanna J Park
- Department of Obstetrics, Gynecology, and Women's Health, University of Medicine and Dentistry of New Jersey (UMDNJ)--New Jersey Medical School, Newark, New Jersey 07103, USA.
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Ragni G, Caliari I, Nicolosi AE, Arnoldi M, Somigliana E, Crosignani PG. Preventing high-order multiple pregnancies during controlled ovarian hyperstimulation and intrauterine insemination: 3 years' experience using low-dose recombinant follicle-stimulating hormone and gonadotropin-releasing hormone antagonists. Fertil Steril 2006; 85:619-24. [PMID: 16500328 DOI: 10.1016/j.fertnstert.2005.09.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 09/06/2005] [Accepted: 09/06/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To employ protocols of mild ovarian stimulation to prevent an excessively elevated rate of high-order multiple pregnancies. DESIGN Case series. SETTING University hospital. PATIENT(S) Six hundred and twenty one consecutive patients undergoing 1,259 controlled ovarian hyperstimulation and intrauterine insemination cycles. INTERVENTION(S) Patients received 50 IU per day of recombinant follicle-stimulating hormone (FSH) starting the third day of the cycle, then a gonadotropin-releasing hormone (GnRH) antagonist on the day in which a follicle > or =13 mm was visualized. Cycles were canceled if three or more follicles > or =16 mm and/or five or more follicles > or =11 mm were detected. MAIN OUTCOME MEASURE(S) Rate of high-order multiple pregnancies. RESULT(S) The clinical pregnancy rate per initiated cycle was 9.2% (95% confidence interval, 7.5-11.1%). The incidence of twins and high-order multiple pregnancies was 9.5% (95% CI, 5.3-16.2%) and 0 (0.0-3.2%), respectively. CONCLUSION(S) In controlled ovarian hyperstimulation and intrauterine insemination cycles, a protocol of 50 IU of recombinant FSH daily combined with the use of GnRH antagonists and a policy of strict cancellation based on echographic criteria are associated with a satisfactory pregnancy rate per initiated cycle and a low risk of high-order multiple pregnancies.
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Affiliation(s)
- Guido Ragni
- Department of Obstetrics-Gynecology, Ospedale Maggiore Policlinico, Mangiagalli and Regina Elena, Italy
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Mamas L. Comparison of fallopian tube sperm perfusion and intrauterine tuboperitoneal insemination: a prospective randomized study. Fertil Steril 2006; 85:735-40. [PMID: 16500346 DOI: 10.1016/j.fertnstert.2005.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 08/09/2005] [Accepted: 08/09/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the results of two different methods of insemination: fallopian tube sperm perfusion (FSP) with 4 mL of inseminate and intrauterine tuboperitoneal insemination (IUTPI) with 10 mL of inseminate. DESIGN Prospective randomized clinical study. SETTING Private infertility center. PATIENT(S) Two hundred seventy-six couples, undergoing 403 cycles, with unexplained infertility, mild or moderate male infertility, or mild or moderate endometriosis. INTERVENTION(S) Patients were assigned randomly to either FSP (group A, n = 138) or IUTPI (group B, n = 138) treatment. Both groups followed the same mild ovarian stimulation protocol. MAIN OUTCOME MEASURE(S) Ninety-five overall pregnancies: 35 in group A (FSP) and 60 in group B (IUTPI). RESULT(S) The pregnancy rate per cycle (presence of gestational sac with heart beats) was 17.6% in group A (n = 199) and 29.4% in group B (n = 204). These differences were statistically significant (P < .007). The odds ratio of getting pregnant, per patient, in group B was 2.26 (95% confidence interval 1.36-3.77) compared with group A. CONCLUSION(S) The results of this study indicate that IUTPI may prove to be a useful technique in the treatment of unexplained infertility, mild or moderate male infertility, and mild or moderate endometriosis. Three attempts of IUTPI may be beneficial before moving on to more invasive and expensive methods of assisted reproduction techniques.
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Abstract
Iatrogenic multiple pregnancy is the most significant complication of assisted reproductive technology (ART). Approximately half of all children born subsequent to ART result from a plural gestation. Furthermore, the majority of triplets and higher order births are the product of ART. The risks for multiple pregnancy vary with practice patterns and the techniques used to achieve pregnancy. Recognizing the potential for serious morbidity associated with multiple pregnancies, infertility specialists have developed strategies to reduce the complication of multiple pregnancies while maintaining acceptable pregnancy rates. Implementation of these refined practices has led to a reduction in the incidence of higher order multiple births, although the incidence of twins has yet to be minimized. Further reduction in the incidence of multiple births after ART necessitates a redefinition of success to emphasize the healthy singleton birth rate, rather than crude pregnancy rates.
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Affiliation(s)
- Gary S Nakhuda
- Division of Reproductive Endocrinology and Infertility, College of Physicians & Surgeons, Columbia University, New York, NY 10032, USA.
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Goverde AJ, Lambalk CB, McDonnell J, Schats R, Homburg R, Vermeiden JPW. Further considerations on natural or mild hyperstimulation cycles for intrauterine insemination treatment: effects on pregnancy and multiple pregnancy rates. Hum Reprod 2005; 20:3141-6. [PMID: 16037113 DOI: 10.1093/humrep/dei175] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The high iatrogenic multiple pregnancy rate associated with intrauterine insemination (IUI) in hyperstimulated cycles is becoming less acceptable. Therefore we investigated data from an earlier prospective trial with regard to the specific question of whether the application of mild hyperstimulation in IUI cycles could be an alternative strategy for obtaining acceptable pregnancy rates while preventing a high multiple pregnancy rate, compared with natural cycles for IUI. METHODS Pregnancy outcome of 310 natural and 334 mildly hyperstimulated cycles for IUI in 171 couples with unexplained or mild male factor subfertility was analysed on a patient level with random coefficient models. RESULTS Pregnancy rates were similar: 35 and 39.8% per couple in the natural and mildly hyperstimulated cycles respectively (P = 0.60). Multiple pregnancies, all twin pregnancies, were conceived significantly more frequently in the mild hyperstimulation group (27% of the pregnancies) than in the natural cycle group (4% of the pregnancies) (P = 0.01). All multiple pregnancies in the hyperstimulation group were conceived in multifollicular cycles. Multifollicular development was strongly associated with the application of mild hyperstimulation only (odds ratio 21.14, 95% confidence interval 8.15-54.79). CONCLUSION The application of a mild hyperstimulation protocol as an alternative to a standard hyperstimulation protocol for IUI does not result in higher pregnancy rates than IUI in the natural cycle, while at the same time multiple pregnancies cannot be avoided. Therefore, there is no place for the use of gonadotrophins in IUI treatment.
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Affiliation(s)
- A J Goverde
- Vrije Universiteit Medical Centre, Department of Reproductive Medicine, Division of Obstetrics and Gynaecology, Amsterdam, The Netherlands.
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Vlahos NF, Coker L, Lawler C, Zhao Y, Bankowski B, Wallach EE. Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin. Fertil Steril 2005; 83:1510-6. [PMID: 15866592 DOI: 10.1016/j.fertnstert.2004.11.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Revised: 11/16/2004] [Accepted: 11/16/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate factors that may affect pregnancy outcome following ovarian stimulation with clomiphene citrate (CC) combined with intrauterine insemination (IUI). DESIGN Retrospective cohort study. SETTING University teaching hospital. PATIENT(S) Three hundred and twenty women who underwent 691 ovarian stimulation cycles with CC for IUI. INTERVENTION(S) Ovarian stimulation with CC followed by a single IUI either 24 hours after a spontaneous serum LH surge (>25 mIU/mL) or 36 hours after intramuscular human chorionic gonadotropin (hCG) administration (10,000 IU) when the largest follicle had reached a diameter of 17 mm. MAIN OUTCOME MEASURE(S) Clinical pregnancies. RESULT(S) Women with ovulatory dysfunction who received hCG had significantly higher pregnancy rates (24.6%) compared with women with other types of infertility. There were no differences in pregnancy rates between the LH surge group and the hCG group (14.3% vs 12.4%). A spontaneous LH surge was noted in a variety of follicular sizes (14 to 35 mm). There was no correlation for age, body mass index, follicular diameter, number of mature follicles, other sperm characteristics, and pregnancy outcome in either group. CONCLUSION(S) After ovarian stimulation with CC, IUI is equally effective 24 hours after a spontaneous LH surge or 36 hours after administration of hCG. Spontaneous LH surges were observed at a variety of follicular sizes with comparable pregnancy rates. In women with ovulatory dysfunction, hCG administration before insemination may be beneficial.
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Affiliation(s)
- Nikos F Vlahos
- The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Richmond JR, Deshpande N, Lyall H, Yates RWS, Fleming R. Follicular diameters in conception cycles with and without multiple pregnancy after stimulated ovulation induction. Hum Reprod 2005; 20:756-60. [PMID: 15608033 DOI: 10.1093/humrep/deh677] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Controlled ovulation induction and intrauterine insemination (OI-IUI) is associated with multiple pregnancies, which are a cause of much concern. No reliable datasets have shown clear criteria for predicting multiple pregnancy. The aim of this study was to eliminate a number of variables by examining only conception cycles to determine ultrasound criteria posing risks of multiple pregnancy. METHODS 112 OI-IUI conception cycles (multiple pregnancy rate 19.6%) were analysed retrospectively to identify factors that may be used to evaluate multiple pregnancy risk. Analyses of ultrasound data on the day of hCG administration allowed study of the role of primary, secondary and tertiary follicle diameters (FD). RESULTS There were no multiple pregnancies in cases where there was a single FD > or = 14 mm, and no higher-order pregnancies where the tertiary follicle measured <14 mm. Follicles with an FD of 15 mm showed an 8% attributable implantation rate. CONCLUSIONS Revision of the criteria for administration of the ovulatory dose of hCG should include the concept that follicles of 15 mm diameter may yield a pregnancy. We suggest that rigorous application of such criteria (critical FD of 16 mm combined with secondary FD evidence) will not reduce the programme pregnancy rate, but will reduce the incidence of multiple conceptions.
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Affiliation(s)
- J R Richmond
- Department of Obstetrics and Gynaecology, Queen Mother's Hospital, Glasgow, G3 8SJ.
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Tur R, Barri PN, Coroleu B, Buxaderas R, Parera N, Balasch J. Use of a prediction model for high-order multiple implantation after ovarian stimulation with gonadotropins. Fertil Steril 2005; 83:116-21. [PMID: 15652896 DOI: 10.1016/j.fertnstert.2004.05.095] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Revised: 05/14/2004] [Accepted: 05/14/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine prospectively the effectiveness in clinical practice of a prediction model for high-order multiple pregnancies (HOMP) (triplets or more). DESIGN Prospective study. SETTING University teaching hospital. PATIENT(S) Eight hundred forty-nine consecutive infertile patients undergoing a total of 1,542 treatment cycles. INTERVENTION(S) Gonadotropin ovarian stimulation or induction of ovulation without IVF MAIN OUTCOME MEASURE(S): Observed and predicted overall pregnancy rates and the incidence of HOMP. RESULT(S) The use of the prediction model (implying cancellation of all cycles at high risk for HOMP) would result in an 8% (95% confidence interval, 6.8%-9.2%) reduction of overall pregnancy rate but also in a 285% (95% CI, 279%-291%) reduction of HOMP. CONCLUSION(S) By using our prediction model, it was possible to maintain a low risk of HOMP with a good pregnancy rate in patients receiving gonadotropin ovarian stimulation or induction of ovulation without IVF.
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Affiliation(s)
- Rosa Tur
- Reproductive Medicine Service, Department of Obstetrics and Gynaecology, Institut Universitari Dexeus, Barcelona, Spain.
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Hohmann FP, Laven JSE, de Jong FH, Fauser BCJM. Relationship between inhibin A and B, estradiol and follicle growth dynamics during ovarian stimulation in normo-ovulatory women. Eur J Endocrinol 2005; 152:395-401. [PMID: 15757856 DOI: 10.1530/eje.1.01871] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the relationship between serum concentrations of inhibin A, inhibin B and estradiol (E(2)) and the number of developing follicles during the administration of exogenous follicle-stimulating hormone (FSH) in various regimens in normo-ovulatory volunteers and to evaluate if inhibins act as suitable markers for the number of developing follicles during ovarian stimulation. DESIGN AND METHODS Serial hormone determinations and assessment of follicle numbers were carried out during unstimulated cycles and during various interventions with exogenous FSH. Subjects were randomized for FSH administration into the following groups: a single high dose (375 IU) during the early follicular phase (group A), 5 consecutive low doses (75 IU/day) starting in the mid follicular phase (group B) or daily low doses (75 IU/day) during the early to late follicular phase (starting on cycle days 3, 5 or 7; groups C, D and E respectively). RESULTS Extending the FSH window increases the number of small antral follicles and hence inhibin B serum concentrations. If such an intervention results in multi-follicular growth, mid follicular phase inhibin B (P = 0.001) as well as late follicular phase inhibin B and inhibin A levels are significantly (P < 0.05 and P < 0.01 respectively) increased compared with mono-follicular cycles or the natural cycle. Although mid follicular inhibin B levels correlated well with the number of small antral (P < 0.05) and pre-ovulatory (P < 0.001) follicles in the late follicular phase, mid follicular inhibin A and estradiol serum concentrations only correlated with the number of pre-ovulatory follicles (P < 0.001 and P < 0.01 respectively). CONCLUSIONS The present data extend our understanding of the relationship between follicle dynamics, serum inhibins and FSH during ovarian hyperstimulation. However, although mid follicular inhibin B does correlate with the number of developing follicles, it does not facilitate the identification of women at risk for multiple follicle development.
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Affiliation(s)
- Femke P Hohmann
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
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Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Risk factors for high-order multiple pregnancy and multiple birth after controlled ovarian hyperstimulation: Results of 4,062 intrauterine insemination cycles. Fertil Steril 2005; 83:671-83. [PMID: 15749497 DOI: 10.1016/j.fertnstert.2004.10.030] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Revised: 10/28/2004] [Accepted: 10/28/2004] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine factors responsible for high-order multiple pregnancy (HOMP) and high-order multiple births when multiple cycles of controlled ovarian hyperstimulation-IUI (COH-IUI) are performed. DESIGN Retrospective analysis. SETTING Private infertility clinic. PATIENT(S) Women (n = 2,272) who underwent 4,067 consecutive COH-IUI cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) High-order multiple pregnancy rate, pregnancy rate (PR), and birth rate (PR) per cycle. RESULT(S) High-order multiple pregnancy was related to number of follicles of diameter > or = 10 mm, age, and treatment cycle. For age <32 years, HOMP was 6% for three to six follicles and 20% for seven or more follicles. For ages 32 to 37 years, HOMP was 5% for three to six follicles and 12% for seven or more follicles. In the first COH-IUI cycle, HOMP was 8% for three to six follicles and 15% for seven or more follicles. In the second cycle, HOMP did not occur unless there were more than six follicles. No HOMP occurred after the second cycle. Pregnancy rate did not increase significantly when there were more than four follicles. Continuing COH-IUI past the third cycle resulted in additional pregnancies in patients with one to eight follicles. CONCLUSION(S) High-order multiple pregnancy can be predicted by age and number of follicles of diameter > or = 10 mm. Controlled ovarian hyperstimulation is not necessary to achieve satisfactory overall pregnancy rates if ovulation induction is continued past the third cycle in low responders.
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Affiliation(s)
- Richard P Dickey
- The Fertility Institute of New Orleans, New Orleans, Louisiana 70128, USA.
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Gómez-Palomares JL, Juliá B, Acevedo-Martín B, Martínez-Burgos M, Hernández ER, Ricciarelli E. Timing ovulation for intrauterine insemination with a GnRH antagonist. Hum Reprod 2005; 20:368-72. [PMID: 15567879 DOI: 10.1093/humrep/deh602] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We aimed to assess the efficacy of a GnRH antagonist in intrauterine insemination (IUI) cycles to increase number of mature ovulatory follicles and pregnancy rates. METHODS Prospective randomized study. Women (18-38 years old) with primary/secondary infertility were included. Eighty-two patients were randomly assigned to controlled ovarian stimulation (COS) consisting of rFSH + GnRH antagonist or rFSH alone. RESULTS A non-significant increase in the total amount of rFSH was seen in the GnRH antagonist group (707+/-240 IU) with respect to the control group (657+/-194 IU). The number of mature follicles (> or =16 mm) was significantly higher in the GnRH antagonist group than in the control group (2.4+/-1.4 versus 1.7+/-1.2, P<0.05). Pregnancy rates were significantly increased in the group of patients receiving the GnRH antagonist (38%) compared to the control group (14%). The only non-single pregnancy (triplets) occurred in the antagonist group. CONCLUSIONS In this preliminary study, adding the GnRH antagonist to the COS protocol for IUI cycles significantly increased pregnancy rates. Nevertheless, these results may not be associated directly with the antagonist itself but with the fact that more mature ovulatory follicles are present by the day of the hCG. Finally, the risk for multiple gestations needs to be carefully evaluated.
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Affiliation(s)
- J L Gómez-Palomares
- Clínica de Medicina de la Reproducción y Ginecología FIVMadrid, Madrid and Unidad de Reproducción, Hospital Severo Ochoa, Madrid, Spain
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Abstract
This review summarizes the existing evidence regarding intrauterine insemination (IUI) as a treatment for cervical hostility, male and unexplained subfertility. IUI in natural cycles has been proven effective in patients with cervical hostility and moderate male subfertility. IUI in cycles with mild ovarian hyperstimulation (MOH) should be the treatment of choice in couples with mild male subfertilty (average total motile sperm count above 10 million) and unexplained subfertilty. When MOH is applied, gonadotropins have been proven more effective compared with clomiphene citrate. Further large trials comparing clomiphene citrate with gonadotropins are mandatory. Prevention of multiple pregnancies in MOH/IUI programs is of paramount importance. A strategy with a low-dose step-up protocol and strict cancellation criteria is proposed. When multiple pregnancies are kept to a minimum, MOH/IUI is more cost-effective compared with in vitro fertilization and embryo transfer. Future research should focus on prediction models to predict the outcome of MOH/IUI treatment for individual couples before starting treatment.
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Affiliation(s)
- B J Cohlen
- Department of Obstetrics and Gynaecology, Isala Clinics Zwolle, Location Sophia, Zwolle, The Netherlands.
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Papageorgiou TC, Guibert J, Savale M, Goffinet F, Fournier C, Merlet F, Janssens Y, Zorn JR. Low dose recombinant FSH treatment may reduce multiple gestations caused by controlled ovarian hyperstimulation and intrauterine insemination. BJOG 2004; 111:1277-82. [PMID: 15521875 DOI: 10.1111/j.1471-0528.2004.00439.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the rate of multiple pregnancies in intrauterine insemination cycles stimulated with a minimal dose of recombinant follicle stimulating hormone (rec-FSH). DESIGN Retrospective study. SETTING University Medical Center. POPULATION A total of 1256 patients underwent 3219 consequent intrauterine insemination cycles with minimal ovarian stimulation. METHODS Patients received 50 or 75 IU of rec-FSH from day four to day seven. The dose was adjusted according to oestradiol (E(2)) levels in order to achieve a maximum of two follicles on the day of hCG administration. MAIN OUTCOME MEASURES Peak E(2) levels, the number of follicles >15 mm and pregnancy rates were calculated. The predictive value of E(2) levels for multiple gestations was also estimated. RESULTS Of 3219 cycles, 334 resulted in pregnancies (10%). Of these, 238 (91%) were singletons, 28 (8%) twins and 1 (0.3%) was a triplet. The cumulative overall pregnancy rate was 43%. Patients over 40 years old had a significantly lower pregnancy rate per cycle and overall live birth rate (P < 0.05). Most pregnancies (83%) occurred during the first three cycles. Pregnancy rates per cycle varied from 8% for tubal factor to 14% for anovulation infertility. CONCLUSIONS Minimal FSH stimulation in intrauterine insemination cycles may reduce the rates of twins and high order multiple pregnancies without affecting overall pregnancy rates.
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Affiliation(s)
- Theocharis C Papageorgiou
- Service Gynécologie-Obstétrique III, Clinique Universitaire Baudelocque, Hôpital Cochin, Paris, France
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Commenges-Ducos M. Place de l'insémination intra-utérine dans la prise en charge de l'infertilité. ACTA ACUST UNITED AC 2004; 32:916-20. [PMID: 15501173 DOI: 10.1016/j.gyobfe.2004.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2004] [Accepted: 07/28/2004] [Indexed: 11/23/2022]
Abstract
The role of intrauterine insemination as treatment for specific factor of infertility and for empiric treatment in idiopathic infertility is hereby described. A review of the different prerequisite evaluations is presented: ovarian age, pelvis evaluation and implantation parameters and negative lifestyle (woman weight and toxics). The efficiency of the treatment as evaluated by different studies is described in terms of pregnancy rate and obstetrical and perinatal outcome. In 2004, the treatment of idiopathic infertility by insemination/ovulation induction is challenged in the face of prevention of multiple pregnancies.
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Affiliation(s)
- M Commenges-Ducos
- Centre de stérilité et de fécondation in vitro, maternité Pellegrin, place Amélie Raba-Léon, 33076 Bordeaux, France.
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Abstract
With increasing age the probability of ongoing pregnancy established by the use of assisted reproduction technology (ART) decreases. As a result the question arises whether age limits for the application of ART should be established. From a literature review and ongoing research data it appears that the costs per child born greatly increase after the age of 40 for both intrauterine insemination with mild ovarian stimulation and in vitro fertilisation treatment, while in cases of 44 and over, prognosis is flat zero. The willingness to pay for extra costs will greatly determine whether and at what age strict limits should be applied. Fortunately, predictive factors for success, like the antral follicle count, may enable the identification of women over 40 and under 44 that still have favourable prospects, thereby decreasing the necessary costs per childbirth and allowing couples into ART programs that are often denied based solely on female age.
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Affiliation(s)
- F J Broekmans
- Division of Reproductive Medicine, Department of Perinatology and Gynecology, University Medical Centre, Huispostnummer F 05.126, Heidelberglaan 100, NL-3584 CX Utrecht, The Netherlands.
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Ibérico G, Vioque J, Ariza N, Lozano JM, Roca M, Llácer J, Bernabeu R. Analysis of factors influencing pregnancy rates in homologous intrauterine insemination. Fertil Steril 2004; 81:1308-13. [PMID: 15136095 DOI: 10.1016/j.fertnstert.2003.09.062] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2003] [Revised: 09/17/2003] [Accepted: 09/17/2003] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify predictors of pregnancy rate (PR) among women undergoing homologous IUI. DESIGN Cross-sectional analysis of IUI cycles carried out from January 2000 to September 2002. SETTING Private infertility center in Alicante, Spain. PATIENT(S) Four hundred seventy women undergoing 1,010 cycles of IUI. INTERVENTION(S) Single IUI with ovarian stimulation using hMG. MAIN OUTCOME MEASURE(S) Preovulatory follicles (>15 mm), motile spermatozoa count, type and duration of infertility, female age, insemination timing, and cycle number. RESULT(S) Overall PR per cycle and multiple pregnancy and miscarriage rates were 9.2%, 8.6%, and 11.8%, respectively. Three significant predictors of pregnancy were identified by multiple logistic regression analysis: preovulatory follicles, spermatozoa count, and infertility duration. Interuterine insemination with three follicles almost tripled the PR with respect to only one, odds ratio (OR) = 2.89 (95% confidence interval [CI], 1.54-5.41). Compared with insemination with a motile sperm count >30 x, 20.1-30, 10.1-20, 5.1-10, and < or =5 x10(6), insemination progressively decreased the PR, from 15.3% in the highest category to 3.6% in the lowest (OR lowest/highest = 0.20 [95% CI: 0.09-0.45]), with a statistically significant dose-response trend. Infertility duration > or =3 years was marginally associated with a lower PR, OR = 0.65 (95% CI, 0.40-1.04). Overall, female age was not a significant predictor of pregnancy, and although PR slightly decreased beyond two IUI cycles and when a single IUI was performed 36-40 hours after hCG administration, results were not statistically significant. CONCLUSION(S) Homologous IUI achieves the best results with two or three induced follicles, a high motile spermatozoa count, and infertility duration <3 years, irrespective of female age and fertility history.
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Adashi EY, Barri PN, Berkowitz R, Braude P, Bryan E, Carr J, Cohen J, Collins J, Devroey P, Frydman R, Gardner D, Germond M, Gerris J, Gianaroli L, Hamberger L, Howles C, Jones H, Lunenfeld B, Pope A, Reynolds M, Rosenwaks Z, Shieve LA, Serour GI, Shenfield F, Templeton A, van Steirteghem A, Veeck L, Wennerholm UB. Infertility therapy-associated multiple pregnancies (births): an ongoing epidemic. Reprod Biomed Online 2004; 7:515-42. [PMID: 14686351 DOI: 10.1016/s1472-6483(10)62069-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Eli Y Adashi
- University of Utah Health Sciences Center, Department of Obstetrics and Gynecology, Salt Lake City, Utah, USA
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Dickey RP, Taylor SN, Lu PY, Sartor BM, Pyrzak R. Clomiphene citrate intrauterine insemination (IUI) before gonadotropin IUI affects the pregnancy rate and the rate of high-order multiple pregnancies. Fertil Steril 2004; 81:545-50. [PMID: 15037400 DOI: 10.1016/j.fertnstert.2003.07.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2003] [Revised: 07/23/2003] [Accepted: 07/23/2003] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine if previous treatment with clomiphene citrate intrauterine insemination (CC-IUI) affects pregnancy and high-order multiple pregnancy (HOMP) rates in subsequent hMG-IUI or FSH-IUI cycles. DESIGN Retrospective cohort study. SETTING Private infertility clinic. PATIENT(S) Five hundred fifty-one patients (age <38 years) without tubal factor infertility, treated with 918 cycles of hMG/FSH-IUI after one or more unsuccessful cycles of CC-IUI; 908 patients treated with 1459 cycles of hMG/FSH-IUI without prior CC-IUI. INTERVENTION(S) CC-IUI, hMG-IUI, FSH-IUI. MAIN OUTCOME MEASURE(S) Pregnancy rate per cycle, HOMP (three or more gestational sacs). RESULT(S) Pregnancy rates during the first three hMG-IUI or FSH-IUI cycles averaged 21.8 +/- 1.1% without previous CC-IUI, 19.6 +/- 1.3% after one to four cycles of CC-IUI, and 3.6 +/- 2.6% after >or= five previous CC-IUI cycles. The HOMP rates were 8.8% without previous CC-IUI, 7.5% after one, 5.7% after two and <2.6% (0 out of 38) after >or= three previous CC-IUI cycles. CONCLUSION(S) Pregnancy rates in hMG/FSH-IUI cycles are significantly reduced after four unsuccessful CC-IUI cycles. High-order multiple pregnancies due to hMG/HMG-IUI are reduced following previous unsuccessful CC-IUI cycles.
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Affiliation(s)
- Richard P Dickey
- The Fertility Institute of New Orleans, New Orleans, Louisiana 70128, USA.
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Abstract
Over the past 15 years, there has been a marked increase in the use of ovulation induction and intrauterine insemination (IUI) for the treatment of unexplained infertility. However, although ovulation induction and IUI have rapidly gained popularity, clinical use is based largely on practical experience rather than on well-designed scientific studies. This article summarizes the evidence in this area. Despite clinical heterogeneity and different methodological qualities of the trials, it can be concluded that ovulation induction significantly improves the probability of conception in couples with unexplained infertility, particularly when associated with IUI. It is remarkable, though, that there has been only one large-scale, randomized trial of ovulation induction plus IUI in the treatment of unexplained infertility in which one of the study arms is an untreated control group. For couples requiring treatment, the complication rate must be minimized, particularly the occurrence of high-order multiple pregnancy. Evaluation of the effectiveness and safety of low-dose gonadotrophin administration in patients with unexplained infertility is limited and further studies are warranted.
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Affiliation(s)
- Juan Balasch
- Institut Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Faculty of Medicine, University of Barcelona, Barcelona, Spain.
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Fritz MA, Ory SJ. Practice guidelines cannot be justified in the absence of sufficient evidence: inaction is far more appropriate than indefensible action. Fertil Steril 2003; 79:22-4. [PMID: 12524056 DOI: 10.1016/s0015-0282(02)04559-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Marc A Fritz
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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