Accurate diagnosis as a prognostic factor in intrauterine insemination treatment of infertile saudi patients

BACKGROUND

The study meant to define the prognostic factors that help in prescribing intrauterine insemination (IUI) for infertility treatment which remains an area of continuous improvements.

METHODS

The diagnostic indications of a cohort of IUI-treated patients and their corresponding pregnancy rates (PRs) were randomly and prospectively studied among Saudi cohort of 303 patients for a period of 20 months. The indications of IUI cases were statistically analyzed for those eligible patients over a period of twenty months (January 2010 till August 2011), and the PR that corresponded to each group was investigated as well. P-value less than 0.05 was considered significant.

RESULTS

The highest PR, 18.87%, of the polycystic ovarian syndrome (PCOS)-only diagnosed patients, was significantly higher than the average PR of all other indications combined, 7.22%, (p = 0.011, compared to all other groups combined). The second highest PR, 14.0%, of the tubal factor (TF)-only indication, was double the PR average of all other indications combined, though it did not reach significance. However, PCOS and TF accompanied by other indications caused the PR to drop to 5.88% and 5.56%, respectively. However, a group of some hormonal-imbalance based indications had the least PR (0.0% to 2.70%). Those indications were elevated serum FSH, hyperprolactinemia, hypogonadotrophy, hypothyroidism and endometriosis. The rest of the indications had an average PR (8.33% to 11.11%).

CONCLUSION

There is a reasonable chance of conception after IUI treatment for female factor infertility except in cases with sever hormonal imbalance. The PCOS cases having the best success chances.

Relationship between Dietary Fat Intake, Its Major Food Sources and Assisted Reproduction Parameters

BACKGROUND

High dietary fat consumption may alter oocyte development and embryonic development. This prospective study was conducted to determine the relation between dietary fat consumption level, its food sources and the assisted reproduction parameters.

METHODS

A prospective study was conducted on 240 infertile women. In assisted reproduction treatment cycle, fat consumption and major food sources over the previous three months were identified. The number of retrieved oocytes, metaphase ΙΙ stage oocytes numbers, fertilization rate, embryo quality and clinical pregnancy rate were also determined. The data were analyzed using multiple regression, binary logistic regression, chi-square and t-test. The p-value of less than 0.05 was considered significant.

RESULTS

Total fat intake adjusted for age, body mass index, physical activity and etiology of infertility was positively associated with the number of retrieved oocytes and inversely associated with the high embryo quality rate. An inverse association was observed between sausage and turkey ham intake and the number of retrieved oocytes. Also, oil intake level had an inverse association with good cleavage rate.

CONCLUSION

The results revealed that higher levels of fat consumption tend to increase the number of retrieved oocytes and were adversely related to embryonic development. Among food sources of fat, vegetable oil, sausage and turkey ham intake may adversely affect assisted reproduction parameters.

Does dehydroepiandrosterone supplementation really affect IVF-ICSI outcome in women with poor ovarian reserve?

OBJECTIVES

It is difficult to choose the correct fertility treatment in women with poor ovarian reserve. Although various methods have been used, the management of controlled ovarian hyperstimulation is not easy in poor responders. The aim of this study was to evaluate the efficacy of dehydroepiandrosterone (DHEA) on in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) outcome of poor responders.

STUDY DESIGN

This was a randomized, prospective controlled trial. Women with serum antimullerian hormone<1 ng/ml or serum follicle-stimulating hormone>15 IU/l and antral follicle count <4 on day 2 of the menstrual cycle were considered to have poor ovarian reserve. All women were treated with a microdose induction protocol. Women in the study group received IVF-ICSI and DHEA 75 mg daily for 12 weeks. Women in the control group received IVF-ICSI without DHEA supplementation.

RESULTS

In total, 208 women with diminished ovarian reserve was enrolled in the study, 104 in the study group and 104 in the control group. The number of oocytes retrieved and the fertilization rate were slightly higher in the study group, but the pregnancy rate was higher in the control group. The differences were not significant.

CONCLUSIONS

The results failed to show that DHEA supplementation enhances IVF-ICSI outcome in women with poor ovarian reserve.

Identification of inadequate maternal progesterone concentrations in nulliparous dairy heifers and treatment with human chorionic gonadotrophin

Plasma progesterone concentrations were estimated for 381 nulliparous dairy heifers from eight farms on days 4-6 after insemination. Heifers were synchronised using two treatments of prostaglandin F2α (PGF2α) 11 days apart. Alternate heifers were treated with 1500 IU human chorionic gonadotrophin (hCG) at the time of sampling, and the pregnancy status assessed ~35 days after insemination. Heifers with no corpus luteum (CL; n-30) at the second PGF2α had lower progesterone concentrations (P<0.001) and pregnancy rates (PR; P=0.001) compared with heifers with CL (n=351, defined as cyclic). The risk of no CL increased in heifers <15 months of age (OR=7.5, P<0.001) and with body condition score <2.5 (OR=4.5, P=0.001). Those with no CL were removed from further analysis. The 20 per cent cyclic control heifers with progesterone concentrations ≤2 ng/ml on days 4-6 had lower PRs compared with those with higher concentrations (42 per cent vs 64 per cent, OR=0.3, P=0.01). There was no overall effect of hCG on PR compared with controls (51 per cent vs 60 per cent, P=0.10). However, heifers with high progesterone on days 4-6 (>2 ng/ml) had a lower PR after treatment (51 per cent vs 64 per cent, OR=0.6, P=0.02). Heifers inseminated with sexed (n=18) compared with conventional (n=333) semen had a decreased PR (33 per cent vs 57 per cent, OR=0.2, P=0.01). This study demonstrates that higher plasma progesterone concentrations as early as days 4-6 after insemination have a positive effect on first insemination PR, but there was no beneficial effect of hCG treatment on these days in dairy heifers.

Cessation of gonadotropin-releasing hormone antagonist on triggering day in flexible multiple-dose protocol: A randomized controlled study

Objective

To investigate outcomes of stimulated IVF cycles in which GnRH antagonist was omitted on the ovulation triggering day.

Methods

A total of 86 women who underwent controlled ovarian hyperstimulation with recombinant FSH and GnRH antagonist flexible multiple-dose protocols were recruited and prospectively randomized into the conventional group (group A) or cessation group (group B). The GnRH antagonist, 0.25 mg/day of cetrorelix, was started when the leading follicle reached 14 mm in diameter and was continuously administered until the hCG triggering day (group A, 43 cycles) or until the day before hCG administration (group B, 43 cycles). The maturity of oocytes, fertilization rate, embryo quality, and implantation and clinical pregnancy rates were evaluated.

Results

The duration of ovarian stimulation, total dose of gonadotropins, serum estradiol levels on hCG administration day, and number of oocytes retrieved were not significantly different between the two groups. The total dose of GnRH antagonist was significantly lower in group B than group A (2.5±0.9 vs. 3.2±0.8 ampoules, p<0.05). There was no premature luteinization in any of the subjects. The proportion of mature oocytes and fertilization rate were not significantly different in group B than group A (70.7% vs. 66.7%; 71.1% vs. 66.4%, respectively). There were no significant differences in the implantation or clinical pregnancy rates.

Conclusion

Our prospective randomized study suggested that cessation of GnRH antagonist on the hCG administration day during a flexible multiple-dose protocol could reduce the total dose of GnRH antagonist without compromising its effects on pregnancy rates.

Comparison of follicular fluid and serum anti-Mullerian hormone levels as predictors of the outcome of assisted reproductive treatment

OBJECTIVE

To compare follicular fluid and serum concentrations of anti-Mullerian hormone (AMH) as predictors of the outcome of assisted reproduction.

STUDY DESIGN

This observational study enrolled 58 women who were undergoing IVF or ICSI treatment with the long stimulation protocol. Patients diagnosed as having PCOS were excluded. Serum and follicular fluid AMH levels were assessed as predictors of clinical pregnancy.

RESULTS

Both the serum and follicular fluid AMH levels were higher in the clinical pregnancy group than in the failed group. A significant correlation was found between the serum and follicular fluid AMH levels, but a discrepancy was observed in some patients with elevated AMH levels in the follicular fluid or serum alone. Assisted reproductive treatment resulted in clinical pregnancy in all of the patients with elevated AMH levels in the follicular fluid (>40pM) or in the serum (>10pM). The ROC-AUC for the combination of follicular and serum AMH was 0.772, which was relatively higher than that for either the serum AMH (AUC: 0.691) or follicular fluid AMH (AUC: 0.688) alone.

CONCLUSION(S)

Elevated AMH levels in either the serum or follicular fluid appeared to be predictive of clinical pregnancy, even if AMH levels in other fluids were low. This is a pilot study with preliminary data that need further confirmation.

Natural conception rate following laparoscopic surgery in infertile women with endometriosis

Objective

To investigate the influence of laparoscopic surgery on the natural conception rate in infertile women with endometriosis during the first year after the operation.

Methods

We retrospectively studied 43 infertile women with surgically proven endometriosis. The natural conception rate was investigated for the 12 months after the laparoscopy.

Results

The overall pregnancy rate was 41.9% (18/43). 66.7% (12/18) and 94.4% (17/18) of the patients conceived within postoperative 3 months and 6 months, respectively. The spontaneous pregnancy rate was not associated with the severity of endometriosis or laparoscopic findings or the type of surgery. The pregnancy rate for stage IV was relatively low (20.0%) compared to stage I, II, and III (35.7%, 44.4%, and 53.3%, respectively), although it did not reach statistical significance.

Conclusion

Conservative surgical treatment with laparoscopy and a prompt attempt at natural conception may be effective for infertile patients with endometriosis.

Predictive factors influencing pregnancy rates after intrauterine insemination

BACKGROUND

So far, many studies investigated factors that affect pregnancy rates after intrauterine insemination (IUI). Various investigators have not agreed on the nature and ranking of these criteria.

OBJECTIVE

The aim of this study was to assess the predictive factors for pregnancy rate after controlled ovarian hyperstimulation (COH)/ IUI.

MATERIALS AND METHODS

Retrospective study of all patients undergoing IUI at Zeynep Kamil Gynecologic and Pediatric Training and Research Hospital from January 2006 to December 2009. In total 980 IUI cycles in 569 couples were analyzed. All women in the study underwent ovarian stimulation using gonadotropin and IUI was performed 36 h after triggering ovulation. The primary outcome measure was clinical pregnancy rates. Predictive factors evaluated were female age, body mass index (BMI), duration of infertility, type of infertility, follicle stimulating hormone (FSH) level and estradiol (E2) on third day of the cycle, number of preovulatory follicles, endometrial thichness, total motil sperm (TMS) count, and ratio of progressive motile sperm.

RESULTS

The overall clinical pregnancy rate was 4.7%. Among the predictive factors after multivariate logistic regression analysis level of BMI (<25 kg/m²), number of preovulatory follicles (≥2), level of FSH (<9.4 IU/L), level of E2 (<80 pg/ml) and the ratio of progressive motile sperm (>50%) significantly influenced the clinical pregnancy rate.

CONCLUSION

Level of BMI, FSH, estradiol, number of preovulatory follicles and the ratio of progressive motile sperm may determine IUI procedure as optimum treatment model.

Surrogacy as a good option for treatment of repeated implantation failure: a case series

BACKGROUND

Repeated implantation failure (RIF) is defined as pregnancy failure after two to six times with at least ten high grade embryo transfer to uterus. A variety of causes have been anticipated for RIF, including anatomical, autoimmune, genetics, endocrine and thrombotic anomalies. Factors responsible for RIF have important implication regarding treatment however in many couples a perfect cause cannot be found.

CASES

In these case series, we reported nine couples with RIF that after investigation no definitive etiology was found for RIF and empirical therapy by heparin, aspirin and or immunotherapy was not effective. In these cases we recommended transfer of embryos to surrogate uterus. Nine patients were studied and six of them developed a normal pregnancy (pregnancy rate=66.66%).

CONCLUSION

This study showed that surrogacy is a good option for treatment of RIF.

Pregnancy predictors after intrauterine insemination: analysis of 3012 cycles in 1201 couples

BACKGROUND

Intrauterine insemination (IUI) is the first therapeutic step in assisted reproductive techniques and many factors, including male and female infertility and technique-dependent factors, have been reported to influence pregnancy rates after IUI.

METHODS

We carried out this retrospective study on 1201 couples undergoing 3012 intrauterine insemination cycles during 2002 to 2009. Pregnancy rate per cycle in terms of female infertility factors, male infertility factors, and technique-dependent factors were evaluated. The χ (2) , t-test, Kaplan-meier method, and multiple logistics regression model, were used for data analysis. The p < 0.05 was considered statistically significant.

RESULTS

The highest pregnancy rates were obtained in cases whose infertility duration was shorter (p < 0.05), Body Mass Index (BMI) was ≥25 (p < 0.05), FSH < 9 IU/L (p < 0.05), anovulation due to polycystic ovary syndrome (p < 0.05), donor sperm was used due to azoospermia (p < 0.01), three IUI cycles (p < 0.01), at least two follicles were recruited through controlled ovarian hyperstimulation (p < 0.01), and where higher total doses of FSH were administered as necessary (p < 0.05).

CONCLUSION

This study characterizes predictors of pregnancy following IUI, for cases with shorter periods of infertility, BMI of 25 or more, FSH value below 9 IU/L, anovulation, donor sperm and performance of three intrauterine insemination cycles.

Correlation between PPARγ protein expression level in granulosa cells and pregnancy rate in IVF program

BACKGROUND

Peroxisome proliferative-activated receptors (PPARs) are nuclear receptors that involved in cellular lipid metabolism and differentiation. The subtype γ of the PPAR family (PPARγ) plays important roles in physiologic functions of ovaries.

OBJECTIVE

To determine correlation between PPARγ protein level in granulosa cells and pregnancy rate in women undergoing in-vitro fertilization (IVF) treatment.

MATERIALS AND METHODS

In this cross-sectional study, twenty-five samples of granulosa cells were collected from women referred to an IVF treatment center. PPARγ protein expression level in granulosa cells was determined in comparison with β-actin level as control gene with Western blot test. Laboratory pregnancy was determined by a rise in blood β-hCG level fourteen days after embryo transfer. Correlation analyses were used to test for associations between the oocytes and pregnancy occurrence as outcome variables and PPARγ protein expression level.

RESULTS

Correlation analysis indicated that there was no significant relationship between granulosa cells PPARγ protein level with IVF parameters including number of matured oocytes and the ratio of fertilized to matured oocytes. Comparison of granulosa cells PPARγ protein level with positive and negative laboratory pregnancy revealed also no significant relationship.

CONCLUSION

According to the results of this study, PPARγ protein level in granulosa cells could not be directly correlated to the success rate of IVF.

Comparison of conventional IVF versus ICSI in non-male factor, normoresponder patients

BACKGROUND

Conventional IVF and ICSI are two common techniques to achieve fertilization. IVF has long been used for treatment of infertility, although it is not an effective treatment in severe male infertility. The use of ICSI has been expanded in severe male factor and fertilization failure after IVF cycle. In spite of the widespread use of ICSI in patients with non-male factor infertility, there is still little evidence to confirm its effectiveness in this population.

OBJECTIVE

To evaluate assisted reproductive technology outcomes between IVF and ICSI cycles in non-male factor, normoresponder patients.

MATERIALS AND METHODS

A total of 220 non-male factors, normoresponder patients who were indicated for ART were enrolled in this study. The patients received standard long GnRH agonist or GnRH antagonist protocols for ovarian stimulation and after oocytes retrieval, the patients were divided into two groups (IVF and ICSI groups). In IVF group (n=112), all of retrieved oocytes were treated by conventional IVF and in ICSI group (n=88), microinjection (ICSI) was done on all of retrieved oocytes.

RESULTS

In IVF group, fertilization and implantation rates were significantly higher than ICSI group (66.22% and 16.67% in IVF group versus 57.46% and 11.17% in ICSI group, respectively). Chemical and clinical pregnancy rates were statistically higher in IVF group as compared with the ICSI group (42.9% vs. 27.3% and 35.7% vs. 21.5%, respectively).

CONCLUSION

According to our study, the routine use of ICSI is not improved fertilization, implantation and chemical pregnancy rates and is not recommended in non-male factor, normozoospermic patients.

Effects of timed artificial insemination following estrus synchronization in postpartum beef cattle

The objectives of this study were to evaluate estrus response and pregnancy rates resulting from timed artificial insemination (AI) following estrus synchronization using CIDR in postpartum beef cattle. A total of 100 cows were randomly divided into three groups. Groups 1, 2 and 3 were artificially inseminated at 48-50 h (n=30), 53-55 h (n=30) and 58-60 h (n=40) after CIDR removal, respectively. Estrus synchronization was carried out using a CIDR containing 1.38 mg progesterone. All cows were given 2 mg estradiol benzoate, intramuscularly on the day of CIDR insertion (D 0). The CIDR was removed after 8 days and 125 μg of prostaglandin F2α (PGF2α) was injected intramuscularly. One day after CIDR removal all cows were given 1 mg of estradiol benzoate intramuscularly (D 9). Cows were observed visually for estrus after removal of CIDR. Between 30 and 32 days after timed AI, pregnancy was determined using transrectal ultrasonography. The first estrus observation which is approximately 32 h after CIDR removal showed no significant difference (P>0.05) among the three groups. The onset response of estrus after 32 h removal of CIDR was less than 10% in all three groups 6.6% (G1), 6.8% (G2) and 7.3% (G3). Furthermore, percentages of estrus response (D 10) following CIDR removal were 76.6%, 75.0% and 77.5%. The difference between on D 9 and D 10 estrus response were statistically significant (P<0.05). The pregnancy rates were 23.3% (G1), 26.6% (G2) and 37.5% (G3), which were not significant (P>0.05).

Usefulness of statistics for establishing evidence-based reproductive medicine

During the last decade, evidence-based medicine has been described as a paradigm shift in clinical practice, and as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients". Appropriate statistical methods for analyzing data are critical for the correct interpretation of the results in proof of the evidence. However, in the medical literature, these statistical methods are often incorrectly interpreted or misinterpreted, leading to serious methodological errors and misinterpretations. This review highlights several important aspects related to the design and statistical analysis for evidence-based reproductive medicine. First, we clarify the distinction between ratios, proportions, and rates, and then provide a definition of pregnancy rate. Second, we focus on a special type of bias called 'confounding bias', which occurs when a factor is associated with both the exposure and the disease but is not part of the causal pathway. Finally, we present concerns regarding misuse of statistical software or application of inappropriate statistical methods, especially in medical research.

The correlation of factors affecting the endometrial thickness with pregnancy outcome in the IUI cycles

BACKGROUND

Many studies have been carried out to understand the effect of endometrial thickness on the reproductive outcome while the factors affecting the pattern itself are still unknown.

OBJECTIVE

To determine the factors such as age and the number of follicles that could affect the endometrial thickness Materials and Methods: This study was conducted as a retrospective study on 680 infertile women considered for intrauterine insemination (IUI). IUI protocol was sequential regimen of clomid and gonadotropin. Endometrial thickness measurement was done on the day of HCG administration. Correlation between endometrial thickness and factors such as age, total follicle numbers, dominant follicle numbers, gonadotropine ampule numbers and pregnancy rate were assessed.

RESULTS

The mean endometrial thickness was 7.2±1.8 mm. The endometrium was thinner in older patients compared with younger ones. But in all age ranges pregnancy rate was higher in endometrial thickness 6< ET≤10 mm (p<0.05).

CONCLUSION

We did not find any correlation between age, number of follicles and gonadotropine ampoules with endometrial thickness but in all age ranges, there is a possibility of higher chance of pregnancy in endometrial thickness 6 < ET≤10 mm.

Outcome of assisted reproductive technology in women aged 40 years and older

BACKGROUND

Human fertility has been declined all over the world. Advanced women's age is one of the most important factors in determining the success of reproduction and ageing has negative impact on ART outcome and advanced female age decreases the chance of live birth rates achieved using ART, especially after 40 years of age.

OBJECTIVE

To evaluate ART outcomes regarding to pregnancy, abortion, cycle cancellation and live birth rates in women 40 years and older.

MATERIALS AND METHODS

A retrospective study was performed on three hundred-thirteen women undergoing ART cycles in the Madar Hospital in Yazd. Women with age ≥ 40 years who indicated for ART enrolled the study regardless of the infertility type or etiology. In this study, we used data from IVF or ICSI cycles using fresh embryo transfer. Follow up was performed in regard to pregnancy, abortion, cycle cancellation and live birth rates.

RESULTS

The mean age of women was 41.87±1.97 years. Chemical pregnancy rate was 8.6% (27/313) per cycle. Clinical pregnancy rate was 3.8% (12/313) per cycle. Spontaneous abortion was observed in 63% (17/27) of patients with positive pregnancy test. The overall cancellation rate was 23.3% per oocytes retrieval. The overall live birth rate per cycle for all women who initiated an ART cycle at age ≥40 years was 3.2% (10/313) that eight of those women were under 42 years old.

CONCLUSION

Based on our results, we suggest that women with age 42 years and above should be advised to use other options, including oocyte donation or adoption.

Influence of cumulus cell coculture and cumulusaided embryo transfer on embryonic development and pregnancy rates

OBJECTIVE

In this study, we aimed to evaluate the influence of autologous cumulus oocyte complex (COC) coculture on embryonic development and quality, and investigate the implantation and pregnancy rates after cumulus-aided embryo transfer in the ICSI-ET cycles.

MATERIAL AND METHODS

Ninety five consecutive infertile women undergoing their first cycle of IVF teratment were included in the study. The cases were divided into two groups. Group 1 consisted of 48 women undergoing ICSI, along with autologous cumulus embryo coculture and cumulus-aided emryo transfer. Group 2 comprised 47 consecutive patients who consented to undergo ICSI and in whom autologous cumulus embryo coculture and cumulus-aided embryo transfer were not performed. Implantation and pregnancy rates were compared between the two groups.

RESULTS

The demographic data and controlled ovarian hyperstimulation parameters were similar in the two groups. The fertilization and cleavage rates were found to be higher in group 1 when compared with group 2 (p=0.03 and 0.001, respectively). There were no statistical significant differences for the implantation and clinical pregnancy rates between the two groups.

CONCLUSION

Usage of autologous COCs as coculture may improve fertilization and cleavage rates. However, cumulus-aided embryo transfer does not produce an increase in implantation and pregnancy rates.