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PubMed2006

Subfertility guidelines in Europe: the quantity and quality of intrauterine insemination guidelines.

BACKGROUND: International collaboration could facilitate systematic development of guidelines to regulate and improve clinical practice. To promote European collaboration in guideline development in reproductive medicine, insight into existing subfertility guidelines in Europe is essential. The study aim was to explore the number and quality of clinical practice guidelines on homologous intrauterine insemination (IUI) in Europe. METHODS: To identify IUI guidelines in Europe, electronic databases and Internet were systematically searched and key experts on assisted reproduction in 25 European countries were questioned. The quality of IUI guidelines was systematically assessed with the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Qualitative methods were used to appraise IUI guideline recommendations and references. RESULTS: National guidelines on IUI are available in four of 25 European countries. The quality of IUI guidelines in Europe is moderate to high, but the recommendations and references differ considerably. CONCLUSIONS: The number of IUI guidelines in Europe is surprisingly small, and differences in their recommendations and references are considerable. To overcome these deficiencies in clinical guidance on IUI care in Europe, a central body with expertise in up-to-date guideline development methodology and sufficient resources could be established in Europe for central selection and international exchange of evidence to support guideline recommendations.

Europe↗
PubMed2006

Luteinized unruptured follicle syndrome: incidence and recurrence rate in infertile women with unexplained infertility undergoing intrauterine insemination.

BACKGROUND: The objective of this study was to determine the incidence and recurrence rate of luteinized unruptured follicle (LUF) syndrome in women with unexplained infertility undergoing intrauterine insemination (IUI). METHODS: A total of 167 women with unexplained infertility who underwent 292 cycles of IUI were enrolled in the study. All patients were treated with clomiphene citrate, 50-150 mg/daily from day 5 to 9 of their menstrual cycle. Ultrasound examination to confirm ovulation was performed on the day of IUI (day 0) and every day thereafter for another 3 days (days 1, 2 and 3). A total of 69 women who failed to conceive in the first cycle and 56 women who failed to conceive in the second cycle underwent second and third cycles, respectively. RESULTS: Of the total 167 patients who underwent first cycle, 42 (25%) had LUF. The incidence of LUF was 56.5% in 69 patients who underwent a second cycle of IUI treatment, of whom 33 patients had LUF in the first cycle with recurrence rate of 78.6%. In 56 patients who underwent 3 consecutive cycles, the incidence of LUF was 58.9% and recurrence rate of 90%. No pregnancies were recorded in patients with LUF during the study period. CONCLUSION: The incidence and recurrence rate of LUF are significantly increased in subsequent cycles of IUI. In these patients, other options of infertility treatment might be justified.

Adult↗
PubMed2006

Intrauterine insemination catheters for assisted reproduction: a systematic review and meta-analysis.

BACKGROUND: Intrauterine insemination (IUI) is the oldest and most practised form of assisted reproduction worldwide. We systematically reviewed the literature so that we could evaluate the use of soft versus firm catheters in subfertile women undergoing IUI. METHODS: Extensive searches were conducted for full-text manuscripts, conference abstracts, ongoing and unpublished trials. Primary outcomes were clinical pregnancy (CPR) and ongoing pregnancy (OPR)/live birth rates (LBRs) per woman. Secondary outcomes were multiple pregnancy rate (MPR) per clinical pregnancy, difficulty cannulating the cervix, bleeding and patient discomfort. Meta-analysis was performed using the Peto-modified Mantel-Haenszel fixed-effect model. RESULTS: Seven randomized trials were identified, and four were excluded. No significant differences were noted for CPR and LBR per woman [OR = 0.96, 95% CI = 0.70-1.32 and OR = 0.82, 95% CI = 0.43-1.58, respectively]. As for the secondary outcomes, MPRs per cycle were also not significantly different. More difficulty was noted with soft catheters and more patient discomfort with firm catheters. Bleeding following the procedure was similar between the two groups. CONCLUSIONS: Catheter choice during IUI does not seem to be a detrimental factor for success, as in other assisted reproduction techniques (ART). More studies are warranted to draw definitive conclusions and support the results of this systematic review.

Catheterization↗
PubMed2006

Comparison of different gonadotrophin preparations in intrauterine insemination cycles for the treatment of unexplained infertility: a prospective, randomized study.

BACKGROUND: A comparison of the effectiveness of different gonadotrophin preparations in intrauterine insemination (IUI) cycles for patients with unexplained infertility was performed. METHODS: Two hundred and forty-one patients were prospectively randomized using computer-generated random numbers into three groups: 81 in the Follitropin alpha (Group I), 80 in the urinary FSH (uFSH) (Group II) and 80 in the hMG (Group III). The primary outcome was clinical pregnancy rate with duration of stimulation, total gonadotrophin dose, number of dominant follicles, clinical pregnancy rate, multiple pregnancy, miscarriage rate and ovarian hyperstimulation syndrome (OHSS) rate being secondary outcomes. RESULTS: Clinical pregnancy rate was significantly higher in the rFSH group (25.9% in Follitropin alpha, 13.8% in uFSH and 12.5% in HMG groups; P = 0.04). There was no significant difference in terms of duration of stimulation, but mean FSH dose consumed per cycle was significantly lower in the recombinant FSH (rFSH) group compared with others (825 IU in Follitropin alpha, 1107 IU in uFSH and 1197 IU in HMG groups; P = 0.001). The number of follicles > or =16 mm diameter was significantly higher in the rFSH group compared with the uFSH and HMG groups (2.6 in Follitropin alpha, 1.3 in uFSH and 1.4 in HMG groups; P = 0.001). CONCLUSION: rFSH may result in a better outcome in IUI cycles for unexplained infertility.

Adult↗
PubMed2006

A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility.

BACKGROUND: Controlled ovarian hyperstimulation with intrauterine insemination (IUI) is a widely accepted treatment for unexplained and male subfertility. No consensus exists about the drug of first choice to be used as hyperstimulation. This randomized multicentre trial using a parallel design compares the efficacy of clomiphene citrate (CC) with that of recombinant FSH (rFSH). METHODS: Couples with primary unexplained or male subfertility were randomized to receive CC or rFSH for ovarian hyperstimulation. The treatment was continued for up to four cycles unless pregnancy occurred. Cycles with more than three follicles were cancelled. Cumulative pregnancy rates and live birth rates were primary outcomes. Cancellation during treatment and multiple birth rates are secondary outcomes. Results were analysed following the intention-to-treat principle. RESULTS: Seventy couples with male subfertility and 68 couples with unexplained subfertility were included. Seventy-one women received CC, and 67 received rFSH. Twenty-seven pregnancies were observed in the CC group (38%) and 23 in the rFSH group (34.3%) relative risk (RR) 1.11 [95% confidence interval (95% CI) 0.71-1.73]. The live birth rate was 28.2% (20/71) and 26.9% (18/67) for CC and rFSH, respectively, RR 1.05 (95% CI 0.61-1.80). Overall, the live birth rates per cycle were 10% for CC-stimulated and 8.7% for rFSH stimulated cycles. The total multiple pregnancy rate was 6.0%. Thirty-five cycles (8.6%) were cancelled because of four or more follicles (CC, n = 17; rFSH, n = 18). CONCLUSIONS: In couples with primary unexplained or male subfertility participating in an IUI program, ovarian hyperstimulation can be achieved by CC or rFSH. No significant difference in live birth rates between CC and rFSH was observed. Being less expensive, CC seems the more cost-effective drug and therefore, can be offered as drug of first choice.

Adult↗
PubMedDate not supplied

Review: parent-child relationships and child development in donor insemination families.

The present article reviews the empirical research regarding the parent-child relationships and the development of children in donor insemination (DI) families. Over the years, follow-up studies have appeared sporadically and, despite the varying quality of the research methods, preliminary findings have emerged. Heterosexual DI parents were psychologically well adjusted and had stable marital relationships. DI parents showed a similar or higher quality of parent-child interaction and a greater emotional involvement with their children compared with naturally conceived families. The majority of studies which investigated several aspects of child development found that, overall, DI children were doing well. Findings with regard to emotional/behavioural development, however, were divergent in that some studies identified an increase of such problems while others did not. A steadily growing group within the DI population is lesbian mother families. More recently, follow-up studies have been carried out among DI children who were raised from birth by two mothers. Despite many concerns about the well-being of these children, no adverse effects of this alternative family structure on child development could be identified. As the DI children in all investigations were still young, our knowledge about the long-term effects of DI remains incomplete.

Child↗
PubMedDate not supplied

Predictive value of normal sperm morphology in intrauterine insemination (IUI): a structured literature review.

The aim of the study was to conduct a structured review of the literature published on the use of normal sperm morphology, as an indicator of male fertility potential in intrauterine insemination (IUI) programmes. Published literature in which normal sperm morphology was used to predict pregnancy outcome in IUI during the period 1984-1998 was reviewed. In total, 421 articles were identified via Medline searches. Eighteen provided data that could be tabulated and analysed. Eight of the analysed studies provided sufficient data for statistical analysis, six studies used the Tygerberg 'strict' criteria, and two the WHO guidelines (1987, 1992). A meta-analysis of the six studies in the strict morphology group yielded a risk difference (RD) between the pregnancy rates achieved in the patients below and above the 4% strict criteria threshold of -0.07 (95% CI: -0.11 to 4.03; P<0.001). The WHO criteria group (1987, 1992) had insufficient data to be analysed. Meta-analysis showed a significant improvement in pregnancy rate above 4% threshold for strict criteria. Accurate evaluation of normal sperm morphology results should be an integral part of evaluating the male factor.

Female↗
PubMedDate not supplied

Intrauterine insemination: a systematic review on determinants of success.

Intrauterine insemination (IUI) is a frequently indicated therapeutic modality in infertility. Here, a systematic review of the literature was performed to examine the current status of clinical and laboratory methodologies used in IUI and the impact of female and male factors on pregnancy success. Emphasis was centred in questioning the following: (i) the value of IUI against timed intercourse; (ii) IUI application with or without controlled ovarian hyperstimulation; (iii) timing and frequency of IUI; and (iv) impact of various parameters (male/female) on the prediction of pregnancy outcome. The odds of multiple pregnancy occurrence and its risk factors, as well as the cost-effectiveness of IUI treatment compared with more complex assisted reproductive technologies are discussed. A computerized literature search was performed including Medline and the Cochrane library, as well as a crossover search from retrieved papers. It is concluded that although IUI is a successful contemporary treatment for appropriately selected cases of female and/or male infertility, further research is needed through well-designed studies to improve the methodologies currently utilized. Importantly, the clinical management of the infertile couple should be performed in an expedited manner taking into consideration the age of the woman, the presence of multifactorial infertility and cost-effectiveness of the available treatment alternatives.

Female↗
PubMed1990

Gonotrophic cycle duration, population age structure, and onset of sugar feeding and insemination of Aedes triseriatus (Diptera: Culicidae).

During two successive summers, laboratory-reared Aedes triseriatus (Say) were marked and released into two woodlots in central Ohio. Several cohorts of two groups of mosquitoes were marked and released: blood-engorged, 10-12-d-old females and unfed, 2-d-old females. The parity of marked mosquitoes captured during daily biting collections were used to estimate the duration of the gonotrophic cycle. The parity rate of unmarked mosquitoes, in conjunction with the cycle estimate, yielded data on age structure and daily survival. Information on the onset of insemination and sugar feeding also was obtained. The mean and median duration of the first gonotrophic cycle, based on females released after blood feeding and later finding the collector, was 12 d. Unfed females required a median of about 8 d to feed on sugar, mate, and locate the collector, but required 22-32 d to sugar feed, mate, find a natural host, become parous, and then find the collector. The median duration of the natural gonotrophic cycle was estimated to take 14 d during warm (22 degrees C) weather. The parity rate of the natural population remained between 29 and 51% during the last 3 mo of each summer. The high proportion parous indicated that daily survival rate of unmarked females was above 0.9. Marked females moved between woodlots for distances as far as 400 m and were more likely to emigrate from the small woodlot than the large one.

Aedes↗
PubMed1996

Preferences for intracytoplasmic sperm injection versus donor insemination in severe male factor infertility: a preliminary report.

With the advent of intracytoplasmic sperm injection (ICSI), our programme noted a drop in the number of couples using donor insemination (DI) for severe male factor infertility. Over the first 8 months in which our infertility programme offered both treatments, 27 consecutive couples scheduled for ICSI and 15 consecutive couples scheduled for DI were evaluated Since all patients in our infertility programme beginning in-vitro fertilization (IVF) with planned ICSI or starting DI undergo a semi-structured psychological interview, the psychologist's clinical notes as well as the medical chart were reviewed and coded retrospectively to determine factors related to a couple's treatment choice. Couples who chose IVF-ICSI over DI had a higher occupational status and included husbands with higher educational levels. Their most common motivation was to have the husband's biological child (93% of couples in the ICSI group). The most common motivation for choosing DI (60% of DI couples) was that IVF was not financially affordable. Choice of treatment was not related to psychological adjustment, the husband having prior biological children, or his risk of passing on a genetic defect to offspring. These preliminary data raise the concern that, with the success of ICSI, DI may change in the USA from being an option dictated by semen quality to a second choice treatment utilized for economic reasons.

Adult↗
PubMed1996

A comparison of single and married recipients of donor insemination.

There has been some controversy surrounding the use of donor insemination (DI) for single women. The purpose of the present study was to compare psychological characteristics of married versus single women who were DI recipients. A total of 17 single women and 17 married women completed psychological questionnaires regarding psychiatric symptomatology, self-esteem, and their attitudes towards DI prior to treatment. There were no significant differences between the groups in psychiatric symptomatology or level of self-esteem. A significant difference was found in the amount of time taken to decide to use DI with single women waiting longer. There were no significant differences between groups in reported concerns about the child. There were significant differences in attitudes towards disclosure with more single than married women reporting that they would tell the child about using DI to conceive.

Adult↗
PubMed1996

Does the absence or presence of seminal fluid matter in patients undergoing ovulation induction with intrauterine insemination?

Sperm preparations for intrauterine insemination (IUI) generally do not include seminal fluid, and it is not known whether the absence of this component affects pregnancy rates. Therefore we evaluated the effect of high intravaginal seminal fluid deposition on clinical pregnancy rates in patients undergoing ovulation induction and IUI therapy. A prospective, randomized, double-blind study was designed for an infertile population in a university-based infertility practice. Patients were randomized to receive high vaginal deposition of either seminal fluid separated from the husband's ejaculate (study group) or normal saline solution (control group). Intercourse was restricted. A comparison of clinical pregnancy rates per cycle between study and control groups showed no significant difference between them [22/164 (13.4%) and 19/155 (12.3%) respectively]. Furthermore, in non-participants with unregulated intercourse, the pregnancy rate per cycle was not significantly different (40/307; 13.0%). Miscarriage rates between the study and control groups were similar. As high intravaginal deposition of seminal fluid at the time of IUI does not improve the clinical pregnancy rate in patients undergoing ovulation induction and IUI therapy, our study suggests that, after ejaculation, clinically significant biological contributions of seminal fluid to the achievement of pregnancy are bypassed by well-timed IUI.

Adult↗
PubMed1996

Discrimination between chronological and ovarian age in infertile women aged 35 years and older: predicting pregnancy using basal follicle stimulating hormone, age and number of ovulation induction/intra-uterine insemination cycles.

A marked decline in fertility rates has been demonstrated in women > 35 years of age. We have previously demonstrated the importance of basal follicle stimulating hormone (FSH) concentrations plus chronological age to predict pregnancies in women aged >/=40 years undergoing ovulation induction therapy. The purpose of the current study was to extend our previous study and determine the impact of age, basal FSH concentrations and ovulation induction/inter-uterine insemination (IUI) treatment cycles on pregnancy rates in infertile women age >/=35 years. This prospective observational study was performed at a tertiary university fertility centre. Assessments of basal hormonal status and ovulation induction protocols were performed. The main outcome measured was clinical pregnancies. A total of 770 treatment cycles in 179 women aged >/=35 years were analysed. The impact of basal FSH concentrations on treatment outcomes could be bifurcated into a favourable group (FSH </=23 mIU/ml) and a poor prognosis group (FSH >/= mIU/ml). A multivariate logistic regression model was generated which accurately predicted pregnancies. There was a high degree of correlation between predicted pregnancies and observed pregnancies (r = 0.86). We conclude that age, number of treatment cycles and the interaction term basal FSH x age are useful and significant predictors of pregnancies in patients aged >/=35 years undergoing ovulation induction/IUI therapy.

Adult↗
PubMed1996

Effectiveness of pentoxifylline in semen preparation for intrauterine insemination.

Pentoxifylline, an inhibitor of cAMP phosphodiesterase activity, favours intracellular cAMP concentration increase. In-vitro treatment of semen with pentoxifylline leads to marked augmentation of sperm motility, enhancement of acrosome reaction, increase of sperm penetration into zona-free hamster oocytes, and protection of the sperm plasma membrane. Such properties indicate that the drug may be a useful tool for semen preparation in assisted reproduction, but its real effectiveness in improving fertilization rates is still uncertain, mainly in association with intrauterine insemination (IUI). Theoretically sperm motility should play an extremely important role for positive results in IUI. Therefore, a retrospective clinical trial was planned in order to evaluate whether addition of pentoxifylline to the previously standardized in-vitro treatment of semen had improved the percentage of pregnancies after homologous IUI. The study involved 55 sterile couples (33 classified infertile for male factor and 22 for other factors) who underwent a total of 150 cycles of homologous IUI: 101 for male factor infertility and 49 for other factors (anovulation n = 26, endometriosis n = 2, idiopathic n = 21). Out of the 101 cycles performed for male factor infertility, 61 underwent the standard preparation of semen and were followed by seven pregnancies (pregnancy rate = 11.5%) while 40 had a semen preparation with pentoxifylline addition and were followed by 11 pregnancies (pregnancy rate = 27.5%) with a significant difference between the two procedures (P < 0.05). Out of the 49 cycles carried out for factors different from male infertility, 10 underwent the standard preparation of semen and were followed by two pregnancies (pregnancy rate = 20.0%), while 39 had pentoxifylline addition and were followed by nine pregnancies (pregnancy rate = 23.1%). The difference between the two groups was not significant. Abortions and malformations were equally distributed in the standard treatment and in the pentoxifylline group.

Animals↗
PubMed1996

Prognostic indicators for intrauterine insemination (IUI): statistical model for IUI success.

A retrospective analysis of 260 completed intrauterine insemination (IUI) cycles was used in an attempt to identify significant variables predictive of treatment success. Couples received a maximum of three IUI cycles for the treatment of anovulation, cervical factors or unexplained infertility. Male factor problems were largely excluded by pretreatment screening. The overall pregnancy rate was 19.6% per completed cycle, the miscarriage rate 15.6%, the multiple pregnancy rate 23.5% and the cancellation rate 19%. Logistic regression identified four significant IUI variables [follicle number (P < 0.005), endometrial thickness (P < 0.005), duration of infertility (P < 0.01) and progressive motility (P < 0.05)] which were the most predictive of IUI success. The chance of conceiving when only one follicle was produced was only 7.6%, whereas with two follicles this chance increased to 26%. These variables were incorporated into a statistical model to allow the prediction of the chance of success in subsequent cycles. We conclude that careful patient selection criteria coupled with successful ovarian stimulation is the model for IUI success.

Adult↗
PubMed1995

Randomized comparison of ovulation induction with and without intrauterine insemination in the treatment of unexplained infertility.

The aim of this prospective randomized controlled study was to determine the possible role of ovulation induction with intrauterine insemination (IUI) in the treatment of unexplained infertility. A total of 100 patients were randomized to receive ovulation induction with or without IUI. All patients were treated with long-course gonadotrophin-releasing hormone analogue (GnRHa), starting in the luteal phase, and exogenous follicle stimulating hormone (FSH) to induce follicular growth. Ovulation was induced using human chorionic gonadotrophin and timed intercourse (TI) was advised 24-48 h later or IUI was effected 36-48 h later. Both the cycle fecundities (21.8 and 8.5%) and the cumulative ongoing pregnancy rates after three cycles (42 and 20%) were significantly higher (P < 0.03) in the IUI group than in the TI group respectively. This is a clear indication that ovulation induction with IUI is an effective treatment method for unexplained infertility, but ovulation induction with TI has a negligible impact in this large group of patients.

Adult↗
PubMed1995

The predictive value of computer-assisted semen analysis in the context of a donor insemination programme.

In this paper we examine the value of both conventional and computer-assisted semen analysis (CASA) using the Hamilton-Thorn HTM-S 2030 in predicting the in-vivo fertility of cryopreserved donor semen. Semen samples were examined prospectively and data on the conventional criteria of semen quality, sperm morphometry and movement were collected. Of 61 ejaculates identified, 33 achieved pregnancies ('successful') and 28 failed to do so ('unsuccessful'), despite insemination into at least four different normal female recipients. When the post-thaw semen profiles were compared, no differences were observed between the two groups in respect of the conventional criteria of semen quality determined by conventional laboratory techniques; however, there were differences in respect of both morphometry and movement characteristics determined by the HTM-S. When multiple logistic regression was used to examine the ability of the variables measured to predict the achievement of pregnancy, the conventional criteria of semen quality were of no value (chi 2 = 6.67, P = 0.353). However, the CASA assessment successfully predicted outcome in 86.9% of cases (chi 2 = 44.3, P = 0.0021). It was concluded that CASA assessment is of significant value in predicting the ability of an ejaculate to achieve pregnancy.

Autoanalysis↗
PubMed1995

Cumulative conception rate following intrauterine artificial insemination with husband's spermatozoa: influence of husband's age.

This paper presents the analysis of 901 cycles of intrauterine artificial insemination with the husband's spermatozoa (AIHIU) in 274 couples who obtained 80 pregnancies. The cumulative pregnancy rate after three cycles of AIHIU was 22% and reached 39% after six cycles. Univariate analysis disclosed two factors of poor prognosis: duration of infertility > 3 years (P = 0.01) and husband's age (P = 0.03). Multivariate analysis revealed that the most significant factor contributing to a decreased likelihood of pregnancy was the age of the husband (P = 0.01), then duration of infertility and dysovulation. The wife's age > or = 35 years did not appear to be of poor prognostic value when taking into consideration the three other factors.

Adult↗