Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination: a meta-analysis

Male factor infertility and ART

For years, the management and treatment of male factor infertility has been 'experience' and not 'evidence' based. Although not evidence-based, current clinical practice involves extensive use of assisted reproductive techniques (ART). Where specific treatments are not indicated or have failed, ART have become popular adjunctive treatments for alleviating male factor infertility. According to the limited evidence available, intrauterine insemination (IUI) may be considered as a first-line treatment in a couple in which the female partner has a normal fertility status and at least 1×10(6) progressively motile spermatozoa are recovered after sperm preparation. If no pregnancy is achieved after 3-6 cycles of IUI, optimized in vitro fertilization (IVF) can be proposed. When less than 0.5×10(6) progressively motile spermatozoa are obtained after seminal fluid processing or sperm are recovered surgically from the testis or epididymis, intracytoplasmic sperm injection (ICSI) should be performed. Although the outcome of no other ART has ever been scrutinized as much before, no large-scale 'macroproblems' have as yet been observed after ICSI. Yet, ICSI candidates should be rigorously screened before embarking on IVF or ICSI, and thoroughly informed of the limitations of our knowledge on the hereditary aspects of male infertility and the safety aspects of ART.

Precision of healthcare systematic review searches in a cross-sectional sample

BACKGROUND

In systematic reviews, search precision is generally traded off against the desire to retrieve all relevant studies; however, there is no published evidence on typical precision values. The objective of this study is to establish typical values for the precision of systematic review searches in healthcare.

METHODS

From an existing cross-sectional sample of 300 MEDLINE-indexed systematic reviews, those that reported the flow of bibliographic records through the review process (n = 109) were examined. Where the ratio of the number of included studies and the number of unique retrievals could be determined, overall and median precision of the search was calculated. Subgroup analyses were conducted by review type (treatment/prevention, diagnosis/prognosis, epidemiology, other), eligible study designs, number of databases searched and for updates of existing systematic reviews.

RESULTS

Precision could be calculated for 94 systematic reviews. The median [interquartile range] precision was 0.029 [0.013, 0.081] with a range of 0.007-0.358. In this sample, precision did not differ significantly in any of the subgroups examined.

IMPLICATIONS

Search precision of approximately 3% was typical in this cross-section of health related systematic reviews. This finding is useful for systematic review teams to gauge review resource needs and for information specialists in evaluating their searches. Copyright © 2011 John Wiley & Sons, Ltd.

Sperm DNA damage or progressive motility: which one is the better predictor of fertilization in vitro?

Sperm progressive motility has been reported to be one of the key factors influencing in vitro fertilization rates. However, recent studies have shown that sperm DNA fragmentation is a more robust predictor of assisted reproductive outcomes including reduced fertilization rates, embryo quality, and pregnancy rates. This study aimed to compare the usefulness of sperm progressive motility and DNA damage as predictive tools of in vitro fertilization rates. Here, 136 couples provided 1,767 eggs with an overall fertilization rate of 64.2%. The fertilization rate in vitro correlated with both sperm progressive motility (r² = 0.236; P = 0.002) and DNA fragmentation (r² = -0.318; P < 0.001). The relative risk of a poor fertilization rate was 9.5 times higher in sperm of men with high DNA fragmentation (>40%) compared with 2.6 times in sperm with poor motility (<40%). Further, sperm DNA fragmentation gave a higher specificity (93.3%) in predicting the fertilization rate than progressive motility (77.8%). Finally, the odds ratio to determine fertilization rate (>70%) was 4.81 (1.89-12.65) using progressive motility compared with 24.18 (5.21-154.51) using DNA fragmentation. This study shows that fertilization rates are directly dependent upon both sperm progressive motility and DNA fragmentation, but sperm DNA fragmentation is a much stronger test.

[Assisted reproductive technologies place]

There are three kinds of infertility treatment: medical treatment, surgical treatment and assisted reproductive technology (ART). ART includes intra uterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART technologies made a lot of progress last years and their field of applications extended. Through literature reviews, IUI is recommended for unexplained infertility and discussed for male or cervical infertility. IVF is recommended for tubal and unexplained infertility. Limits between IVF and ICSI in case of male infertility remains unclear. In non mal infertility ICSI is not recommended.

Intra-uterine insemination versus fallopian tube sperm perfusion for non-tubal infertility

BACKGROUND

Controlled ovarian hyperstimulation (COH) combined with intrauterine insemination (IUI) is commonly offered to couples with subfertility that does not involve the fallopian tubes. Another method is fallopian tube sperm perfusion (FSP). This technique ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. The aim of this review was to determine whether FSP and IUI differ in improving the probability of conception.

OBJECTIVES

To investigate whether pregnancy and live birth outcomes differ between fallopian tube sperm perfusion and intrauterine insemination in the treatment of non-tubal subfertility.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Trials Register (October 2008), MEDLINE (January 1966 to October 2008), and EMBASE (January 1988 to October 2008). Abstracts of the American Society for Reproductive Medicine (1987 to 2008) and European Society for Human Reproduction and Embryology (1987 to 2008) meetings were searched using the same key or text words.

SELECTION CRITERIA

Only truly randomised controlled studies comparing FSP with IUI were included in this review. Couples with non-tubal subfertility who have been trying to conceive for at least one year were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials for inclusion based on the quality of the studies.

MAIN RESULTS

Eight studies involving 595 couples were included in the meta-analysis. Only one study reported the live birth rate and there was no evidence of a difference between FSP and IUI (OR 1.2, 95% CI 0.39 to 3.5). There was no evidence of a difference between FSP and IUI for clinical pregnancy per couple (OR 1.2, 95% CI 0.79 to 1.7). A subgroup analysis which included couples with unexplained subfertility only (n = 239) did not report any difference between FSP and IUI (OR 1.6, 95% CI 0.89 to 2.8).

AUTHORS' CONCLUSIONS

For non-tubal subfertility, the results indicate no clear benefit for FSP over IUI. Therefore the advice offered to subfertile couples regarding the comparative use of FSP versus IUI in the treatment of non-tubal subfertility should reflect this.

Intrauterine insemination and male subfertility

In this article we define male subfertility, review clinical indications for the use of intrauterine insemination, evaluate insemination preparation and administration technique, and ultimately advocate for its use as a first-line therapy in the treatment of infertile couples with male subfertility.

Cervical insemination versus intra-uterine insemination of donor sperm for subfertility

BACKGROUND

Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples. Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus. Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates.

OBJECTIVES

To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm.

SEARCH STRATEGY

The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved.

SELECTION CRITERIA

Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available.

DATA COLLECTION AND ANALYSIS

Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed.

MAIN RESULTS

The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96).

AUTHORS' CONCLUSIONS

The findings of this systematic review support the use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.

Intra-uterine insemination for male subfertility

BACKGROUND

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with ovarian hyperstimulation (OH) has been subject of discussion. Although the treatment itself is less invasive and expensive than others, its efficacy has not been proven. Furthermore, the adverse effects of OH such as ovarian hyperstimulation syndrome (OHSS ) and multiple pregnancy are a concern.

OBJECTIVES

The aim of this review was to determine whether for couples with male subfertility, IUI improves the live birth rates or ongoing pregnancy rates compared with timed intercourse (TI), with or without OH.

SEARCH STRATEGY

We searched the Cochrane Menstrual and Disorders Subfertility Group Trials Special Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, 2006, issue 3), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), SCIsearch and the reference lists of articles. We hand searched abstracts of the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology. Authors of identified articles were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCT's) with at least one of the following comparisons were included: 1) IUI versus TI or expectant management both in natural cycles 2) IUI versus TI both in cycles with OH 3) IUI in natural cycles versus TI + OH 4) IUI + OH versus TI in natural cycles 5) IUI in natural cycles versus IUI + OH. Couples with abnormal sperm parameters only were included.

DATA COLLECTION AND ANALYSIS

Two co-reviewers independently performed quality assessment and data extraction. Where possible data were pooled, and a meta-analysis was performed. Sensitivity and subgroup analyses were carried out where possible and appropriate.

MAIN RESULTS

Three trials of parallel design, and five trials of cross-over design with pre-cross-over data were included in the meta-analysis. Three compared IUI with TI both in stimulated cycles. The remaining four of these studies compared IUI versus IUI + OH . Three studies reported on our main outcome of interest live birth rate per couple. For the comparison IUI versus TI both in natural cycles no evidence of difference between the probabilities of pregnancy rates per woman after IUI compared with TI was found (Peto OR 5.3, 95% CI 0.42 to 67). No statistically significant of difference between pregnancy rates (PR) per couple for IUI + OH versus IUI could be found (Peto OR 1.47, 95% CI 0.92 to 2.37). For the comparison IUI versus TI both in stimulated cycles there was no evidence of statistically significant difference in pregnancy rates per couple either (Peto OR 1.67, 95% CI 0.83 to 3.37). There were insufficient data available for adverse outcomes such as OHSS, multiple pregnancy, miscarriage rate and ectopic pregnancy to perform a statistical analysis. For the other two comparisons no RCT's were found which reported pregnancy rates per couple. A further 10 studies which included one of the comparisons of interests were found. Since these studies reported pregnancy rates per cycle only these data could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence of effectiveness to recommend or advise against IUI with or without OH above TI, or vice versa. Large, high quality randomised controlled trials, comparing IUI with or without OH with pregnancy rate per couple as the main outcome of interest are lacking. There is a need for such trials since firm conclusions cannot be drawn yet.

Intra-uterine insemination for male subfertility

BACKGROUND

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with ovarian hyperstimulation (OH) has been subject of discussion. Although the treatment itself is less invasive and expensive than others, its efficacy has not been proven. Furthermore, the adverse effects of OH such as ovarian hyperstimulation syndrome (OHSS ) and multiple pregnancy are a concern.

OBJECTIVES

The aim of this review is to determine whether for couples with male subfertility, IUI improves the live birth rates or ongoing pregnancy rates compared with timed intercourse (TI), with or without OH.

SEARCH STRATEGY

We searched the Cochrane Menstrual and Disorders Subfertility Group Trials Special Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, 2006, issue 3), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), SCIsearch and the reference lists of articles. We hand searched abstracts of the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology. Authors of identified articles were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCT's) with at least one of the following comparisons were included: 1) IUI versus TI or expectant management both in natural cycles 2) IUI versus TI both in cycles with OH 3) IUI in natural cycles versus TI + OH 4) IUI + OH versus TI in natural cycles 5) IUI in natural cycles versus IUI + OH Couples with abnormal sperm parameters only were included.

DATA COLLECTION AND ANALYSIS

Two co-reviewers independently performed quality assessment and data extraction. Where possible data were pooled, and a meta-analysis was performed. Sensitivity and subgroup analyses were carried out where possible and appropriate.

MAIN RESULTS

Three trials of parallel design, and five trials of cross-over design with pre-cross-over data were included in the meta-analysis. Three compared IUI with TI both in stimulated cycles. The remaining four of these studies compared IUI versus IUI + OH . Three studies reported on our main outcome of interest live birth rate per couple. For the comparison IUI versus TI both in natural cycles no evidence of difference between the probabilities of pregnancy rates per woman after IUI compared with TI was found (Peto OR 5.3, 95% CI 0.42 to 67). No statistically significant of difference between pregnancy rates (PR) per couple for IUI + OH versus IUI could be found (Peto OR 1.47, 95% CI 0.92 to 2.37). For the comparison IUI versus TI both in stimulated cycles there was no evidence of statistically significant difference in pregnancy rates per couple either (Peto OR 1.67, 95% CI 0.83 to 3.37). There were insufficient data available for adverse outcomes such as OHSS, multiple pregnancy, miscarriage rate and ectopic pregnancy to perform a statistical analysis. For the other two comparisons no RCT's were found which reported pregnancy rates per couple. A further 10 studies which included one of the comparisons of interests were found. Since these studies reported pregnancy rates per cycle only these data could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence of effectiveness to recommend or advise against IUI with or without OH above TI, or vice versa. Large, high quality randomised controlled trials, comparing IUI with or without OH with pregnancy rate per couple as the main outcome of interest are lacking. There is a need for such trials since firm conclusions cannot be drawn yet.

Ovulatory status and follicular response predict success of clomiphene citrate-intrauterine insemination

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.

IUI in male subfertility: are we able to select the proper patients?

There is at this time no indication as to which semen parameters from the fertility work-up discriminate between couples with male subfertility who will and will not benefit from intrauterine insemination (IUI). This study evaluated the predictive capacity of semen parameters (both pre- and post-wash) and antisperm antibodies (ASA) obtained during the fertility workup on IUI outcome in couples with male subfertility in a retrospective cohort study. It included 290 couples, who underwent 722 IUI cycles. The overall ongoing pregnancy rate was 9% per cycle. Model I, with female age, duration of subfertility, secondary subfertility, the presence of anovulation, cervical hostility and cycle number had an area under the curve (AUC) of 0.59. Adding the presence of ASA to this model improved the AUC to 0.65 (model II). Further addition of the post-wash total motile count (TMC) to the model with ASA (model III) improved the AUC to 0.67. Using the models to exclude couples from IUI due to low expected pregnancy rates would increase the pregnancy rate to 11% per cycle with model I, and to 14% per cycle for model II and for model III. In conclusion, in the selection of patients with male subfertility for IUI, the use of prediction models including ASA can increase the efficiency of IUI.

Further considerations on natural or mild hyperstimulation cycles for intrauterine insemination treatment: effects on pregnancy and multiple pregnancy rates

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.